Provider Demographics
NPI:1053774323
Name:WILDS, FATIMA (LPN)
Entity type:Individual
Prefix:
First Name:FATIMA
Middle Name:
Last Name:WILDS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8643 BODKIN CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-7358
Mailing Address - Country:US
Mailing Address - Phone:336-225-6912
Mailing Address - Fax:
Practice Address - Street 1:8643 BODKIN CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-7358
Practice Address - Country:US
Practice Address - Phone:336-225-6912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-03
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC81405164W00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1053774323Medicaid