Provider Demographics
NPI:1972514537
Name:WILDER, TRACIE E (APRN)
Entity type:Individual
Prefix:MS
First Name:TRACIE
Middle Name:E
Last Name:WILDER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 20TH AVE N
Mailing Address - Street 2:SUITE 702
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2131
Mailing Address - Country:US
Mailing Address - Phone:615-284-8636
Mailing Address - Fax:615-284-8637
Practice Address - Street 1:300 20TH AVE N
Practice Address - Street 2:SUITE 702
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2131
Practice Address - Country:US
Practice Address - Phone:615-284-8636
Practice Address - Fax:615-284-8637
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN11968363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3644997Medicaid
TN3644997Medicaid
MW1395777OtherDEA