Provider Demographics
NPI:1932819265
Name:WILDESEN, TAMMY ANN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:ANN
Last Name:WILDESEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1952 NEW CREEK HWY
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-7494
Mailing Address - Country:US
Mailing Address - Phone:304-597-3522
Mailing Address - Fax:
Practice Address - Street 1:1952 NEW CREEK HWY
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-7494
Practice Address - Country:US
Practice Address - Phone:304-597-3522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP29110164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse