Provider Demographics
NPI:1518785948
Name:WILDRICK, MARISA KAY
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:KAY
Last Name:WILDRICK
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 1:7400 N 60TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68152-2013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7400 N 60TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68152-2013
Practice Address - Country:US
Practice Address - Phone:531-299-2122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3747P1801X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant