Provider Demographics
NPI:1124882493
Name:WILDERMUTH, SARRA (BSN- RN)
Entity type:Individual
Prefix:
First Name:SARRA
Middle Name:
Last Name:WILDERMUTH
Suffix:
Gender:F
Credentials:BSN- RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 HILLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-8064
Mailing Address - Country:US
Mailing Address - Phone:828-578-5872
Mailing Address - Fax:
Practice Address - Street 1:1881 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453-8083
Practice Address - Country:US
Practice Address - Phone:757-683-4297
Practice Address - Fax:757-683-5253
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001295447163W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse