Provider Demographics
NPI:1053182105
Name:WILDE, PENNIE
Entity type:Individual
Prefix:
First Name:PENNIE
Middle Name:
Last Name:WILDE
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 1:3130 SUMMERWIND CIR
Mailing Address - Street 2:
Mailing Address - City:WINNEMUCCA
Mailing Address - State:NV
Mailing Address - Zip Code:89445-7604
Mailing Address - Country:US
Mailing Address - Phone:904-504-0312
Mailing Address - Fax:
Practice Address - Street 1:3130 SUMMERWIND CIR
Practice Address - Street 2:
Practice Address - City:WINNEMUCCA
Practice Address - State:NV
Practice Address - Zip Code:89445-7604
Practice Address - Country:US
Practice Address - Phone:904-504-0312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide