Provider Demographics
NPI:1821401993
Name:WILDMAN, ELIZABETH ANN (LPN)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANN
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7934 N TOWNSHIP ROAD 72B
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-8525
Mailing Address - Country:US
Mailing Address - Phone:567-207-8386
Mailing Address - Fax:
Practice Address - Street 1:7934 N TOWNSHIP ROAD 72B
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8525
Practice Address - Country:US
Practice Address - Phone:567-207-8386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN095901164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse