Provider Demographics
NPI:1215462247
Name:WILDER, COURTNEY (WELLNESS COACH)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:WELLNESS COACH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S HIGH ST
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523-3818
Mailing Address - Country:US
Mailing Address - Phone:580-298-2830
Mailing Address - Fax:580-298-6723
Practice Address - Street 1:2816 E JACKSON ST
Practice Address - Street 2:SUITE C
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4250
Practice Address - Country:US
Practice Address - Phone:580-326-5350
Practice Address - Fax:580-326-5320
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100744370Medicaid