Provider Demographics
NPI:1720857642
Name:WILDE, MADISON ANN
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ANN
Last Name:WILDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 PREMIER DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6048
Mailing Address - Country:US
Mailing Address - Phone:507-720-0920
Mailing Address - Fax:
Practice Address - Street 1:1700 PREMIER DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6048
Practice Address - Country:US
Practice Address - Phone:507-720-0920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician