Individual
NANETTE WILDE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OTR
Contact information
Practice address
1102 WINKLER AVE, KILLEEN, TX 76542
(254) 634-8505
(254) 781-4312
Mailing address
605 DONNIE AVE, KILLEEN, TX 76541-8918
(254) 634-8505
(254) 781-4312
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
113768
TX
225XP0200X
Pediatric Occupational Therapist
Primary
113768
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0031DG
BLUE CROSS BLUE SHIELD
—
05
—
0944746-02
—
TX
Enumeration date
03/30/2012
Last updated
05/29/2019
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