Provider Demographics
NPI:1649349002
Name:WILDER, RHONDA DAVIDSON (PT)
Entity type:Individual
Prefix:MRS
First Name:RHONDA
Middle Name:DAVIDSON
Last Name:WILDER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6255 HINES HILL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312
Mailing Address - Country:US
Mailing Address - Phone:850-562-2139
Mailing Address - Fax:850-562-2139
Practice Address - Street 1:1803 MICCOSUKEE COMMONS DRIVE STE 202
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-402-0200
Practice Address - Fax:850-402-0564
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH0004393124Q00000X
FLPT19219225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered124Q00000XDental ProvidersDental Hygienist
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY063ROtherBCBS