Provider Demographics
NPI:1790379618
Name:WILDEMAN, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WILDEMAN
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 1:10400 FAR VIEW DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47712-8946
Mailing Address - Country:US
Mailing Address - Phone:812-306-4757
Mailing Address - Fax:
Practice Address - Street 1:926 MAIN ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37206-3614
Practice Address - Country:US
Practice Address - Phone:615-436-9060
Practice Address - Fax:615-235-9725
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28203347A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily