Provider Demographics
NPI:1124276977
Name:WILDER, MARY DELORIS (RN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:DELORIS
Last Name:WILDER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:DELORIS
Other - Last Name:SLOAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9851 W. DEAN RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224
Mailing Address - Country:US
Mailing Address - Phone:414-365-6463
Mailing Address - Fax:414-365-6463
Practice Address - Street 1:9851 W. DEAN RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224
Practice Address - Country:US
Practice Address - Phone:414-365-6463
Practice Address - Fax:414-365-6463
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI90455-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35064200Medicaid
33/075OtherINDEPENDENT NURSE RN