Provider Demographics
NPI:1427870401
Name:WILDER, KRISTINE LYNNETTE
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:LYNNETTE
Last Name:WILDER
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 1:420 KELLOGG AVE.
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010
Mailing Address - Country:US
Mailing Address - Phone:515-232-4977
Mailing Address - Fax:
Practice Address - Street 1:22 N. CENTER ST.
Practice Address - Street 2:
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158
Practice Address - Country:US
Practice Address - Phone:641-752-2300
Practice Address - Fax:641-752-4768
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA128819101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health