Provider Demographics
NPI:1962943829
Name:WILDER, KIYEESHA
Entity type:Individual
Prefix:
First Name:KIYEESHA
Middle Name:
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 1:17295 PALMER ST
Mailing Address - Street 2:2
Mailing Address - City:MELVINDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48122-1247
Mailing Address - Country:US
Mailing Address - Phone:248-469-3898
Mailing Address - Fax:
Practice Address - Street 1:17295 PALMER ST
Practice Address - Street 2:2
Practice Address - City:MELVINDALE
Practice Address - State:MI
Practice Address - Zip Code:48122-1247
Practice Address - Country:US
Practice Address - Phone:248-469-3898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-12
Last Update Date:2017-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide