Provider Demographics
NPI:1750556148
Name:WILDER CLINIC, LLC
Entity type:Organization
Organization Name:WILDER CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:901-857-8925
Mailing Address - Street 1:201 LAKEVIEW RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SOMERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38068-9742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 LAKEVIEW RD
Practice Address - Street 2:SUITE A
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-9742
Practice Address - Country:US
Practice Address - Phone:901-857-8925
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN6154363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty