Provider Demographics
NPI:1841311446
Name:WILDER, LISA L (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:WILDER
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 1:135 WEST 3RD STREET
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38503-0938
Mailing Address - Country:US
Mailing Address - Phone:931-526-2488
Mailing Address - Fax:931-526-6332
Practice Address - Street 1:135 WEST 3RD STREET
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38503-0938
Practice Address - Country:US
Practice Address - Phone:931-526-2488
Practice Address - Fax:931-526-6332
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12727363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily