Provider Demographics
NPI:1831671023
Name:WILDEMAN, JENNIFER L (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WILDEMAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 S KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:KS
Mailing Address - Zip Code:67654-2111
Mailing Address - Country:US
Mailing Address - Phone:785-622-4254
Mailing Address - Fax:785-622-4256
Practice Address - Street 1:112 S KANSAS AVE
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:KS
Practice Address - Zip Code:67654-2111
Practice Address - Country:US
Practice Address - Phone:785-622-4254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-95694-111163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse