Provider Demographics
NPI:1316062441
Name:WILDER, JESSICA (CNM)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:PELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:345 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-2348
Mailing Address - Country:US
Mailing Address - Phone:203-752-2850
Mailing Address - Fax:203-752-8785
Practice Address - Street 1:111 POINT STREET
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-1142
Practice Address - Country:US
Practice Address - Phone:401-421-9620
Practice Address - Fax:401-421-9668
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMW00117367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife