Provider Demographics
NPI:1053950261
Name:WILDE, EMMA KATHLEEN
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:KATHLEEN
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 1:94 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01832-5467
Mailing Address - Country:US
Mailing Address - Phone:815-236-6818
Mailing Address - Fax:
Practice Address - Street 1:148 WARREN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2208
Practice Address - Country:US
Practice Address - Phone:978-452-1736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker