Provider Demographics
NPI:1164683967
Name:WILDE, KATHLYN VALLEAU (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLYN
Middle Name:VALLEAU
Last Name:WILDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 MOLLISON WAY
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5805
Mailing Address - Country:US
Mailing Address - Phone:207-784-5784
Mailing Address - Fax:207-783-9268
Practice Address - Street 1:33 MOLLISON WAY
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5805
Practice Address - Country:US
Practice Address - Phone:207-784-5784
Practice Address - Fax:207-783-9268
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101261046208000000X
390200000X
MEMD25564208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program