Provider Demographics
NPI:1467277996
Name:WILDER, MACKENZIE DANIELLE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:DANIELLE
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 1:269 VALLEY FORGE ST
Mailing Address - Street 2:
Mailing Address - City:BELLE CHASSE
Mailing Address - State:LA
Mailing Address - Zip Code:70037-1075
Mailing Address - Country:US
Mailing Address - Phone:843-476-0637
Mailing Address - Fax:
Practice Address - Street 1:269 VALLEY FORGE ST
Practice Address - Street 2:
Practice Address - City:BELLE CHASSE
Practice Address - State:LA
Practice Address - Zip Code:70037-1075
Practice Address - Country:US
Practice Address - Phone:843-476-0637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer