Provider Demographics
NPI:1538811633
Name:WILDERMUTH, DIANA J
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:J
Last Name:WILDERMUTH
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 1:337 WYANDOTTE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3946
Mailing Address - Country:US
Mailing Address - Phone:740-304-2437
Mailing Address - Fax:
Practice Address - Street 1:637 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-2446
Practice Address - Country:US
Practice Address - Phone:740-974-9245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care