Provider Information for 1063613487
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Ms. KATRINA TALIAFERRIO WILDER MSW
Sex: Female
NPI: 1063613487
Last Updated: 2007-07-08
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
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| NPI | 1063613487 | ||||||||
| Enumeration Date | 2007-05-31 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | 7841 ZANE AVE N 205 BROOKLYN PARK, MN 55443-3086 United States Phone: 763-566-4832 | Fax: | ||||||||
| Primary Practice Address | 4801 VETERANS DR SAINT CLOUD, MN 56303-2015 United States Phone: 320-252-1670 | Fax: | ||||||||
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