Provider Demographics
NPI:1285739417
Name:WILDS, DAENA C
Entity type:Individual
Prefix:
First Name:DAENA
Middle Name:C
Last Name:WILDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 AMBERLEY WAY
Mailing Address - Street 2:STE. A
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8979
Mailing Address - Country:US
Mailing Address - Phone:859-623-4458
Mailing Address - Fax:859-623-4459
Practice Address - Street 1:1036 AMBERLEY WAY
Practice Address - Street 2:STE. A
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-8979
Practice Address - Country:US
Practice Address - Phone:859-623-4458
Practice Address - Fax:859-623-4459
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0136231H00000X
KY0532237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACB5773OtherRR MEDICARE GRP
KYK117240OtherMEDICARE PTAN
GA640004124OtherRR MEDICARE PIN
KYK117240OtherMEDICARE PTAN
KY70005327Medicaid