Provider Demographics
NPI:1801760061
Name:WILDS, CARRIE A (LAC)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:A
Last Name:WILDS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7009 N RIDGE BLVD APT 2S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-3574
Mailing Address - Country:US
Mailing Address - Phone:347-806-9523
Mailing Address - Fax:
Practice Address - Street 1:1630 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3808
Practice Address - Country:US
Practice Address - Phone:773-276-2801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-01
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.011855171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist