Provider Demographics
NPI:1659687283
Name:WILDER, JOANNA LOUISE (APRN-NP, CNM, CPM)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:LOUISE
Last Name:WILDER
Suffix:
Gender:F
Credentials:APRN-NP, CNM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12665 SW HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6217
Mailing Address - Country:US
Mailing Address - Phone:503-896-0170
Mailing Address - Fax:971-264-5335
Practice Address - Street 1:12665 SW HALL BLVD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6217
Practice Address - Country:US
Practice Address - Phone:503-896-0170
Practice Address - Fax:971-264-5335
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10001034367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife