Provider Demographics
NPI:1902612039
Name:WILD, CHRISTINA DAWN
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:DAWN
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 1:407 BLUE RIDGE MANOR DR APT D-7
Mailing Address - Street 2:
Mailing Address - City:WELLSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26070-1967
Mailing Address - Country:US
Mailing Address - Phone:304-975-5007
Mailing Address - Fax:
Practice Address - Street 1:407 BLUE RIDGE MANOR DR APT D-7
Practice Address - Street 2:
Practice Address - City:WELLSBURG
Practice Address - State:WV
Practice Address - Zip Code:26070-1967
Practice Address - Country:US
Practice Address - Phone:304-975-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1821206228Medicaid
WV1356607394Medicaid
WV125553494Medicaid