Provider Demographics
NPI:1053199042
Name:WILDERSON, PAMELA RAE (MS)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:RAE
Last Name:WILDERSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 CAMINO DEL RIO STE 221
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5466
Mailing Address - Country:US
Mailing Address - Phone:970-247-3261
Mailing Address - Fax:
Practice Address - Street 1:425 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:DOVE CREEK
Practice Address - State:CO
Practice Address - Zip Code:81324
Practice Address - Country:US
Practice Address - Phone:970-677-2296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist