Provider Demographics
NPI:1720073455
Name:WILDENHAIN, JOAN T (NP)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:T
Last Name:WILDENHAIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MILL RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:479 SWANSEA MALL DR
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:MA
Practice Address - Zip Code:02777-4119
Practice Address - Country:US
Practice Address - Phone:508-973-1550
Practice Address - Fax:508-973-0386
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN225095363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110105942AMedicaid
MAS400251371Medicare PIN
RIU400265804Medicare PIN
306542OtherRI BLUE CROSS
805910OtherCHIP
RI7007070Medicaid
405910OtherRI BLUE CHIP
RI2036OtherBC