Provider Demographics
NPI:1053558874
Name:WILDE, ANNABELLE MICHELA (PT)
Entity type:Individual
Prefix:
First Name:ANNABELLE
Middle Name:MICHELA
Last Name:WILDE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 BROADWAY
Mailing Address - Street 2:15TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-5882
Mailing Address - Country:US
Mailing Address - Phone:212-877-5580
Mailing Address - Fax:212-877-0388
Practice Address - Street 1:1995 BROADWAY
Practice Address - Street 2:15TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-5882
Practice Address - Country:US
Practice Address - Phone:212-877-5580
Practice Address - Fax:212-877-0388
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031845225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
A400022459Medicare PIN