Provider Demographics
NPI:1699943175
Name:WILD, COURTNEY ANN
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:ANN
Last Name:WILD
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 1:1233 E 39TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-1825
Mailing Address - Country:US
Mailing Address - Phone:909-528-8274
Mailing Address - Fax:
Practice Address - Street 1:164 W HOSPITALITY LN
Practice Address - Street 2:SUITE 1-A
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3316
Practice Address - Country:US
Practice Address - Phone:909-891-1880
Practice Address - Fax:909-891-1888
Is Sole Proprietor?:No
Enumeration Date:2008-02-18
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator