| Doctor Name: | MS. ANGELLUN VANESSA WILDER |
| NPI Number: | 1346416096 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LCSW |
| License Number: | 2176 |
| Business Practice Address: | 3004 Knight St Bldg 6 Shreveport, LA - 711052502 |
| Business Phone Number: | 3186036874 |
| Business Fax Number: | |
| Mailing Address: | 4443 Pines Rd, SHREVEPORT |
| State: | LA |
| Postal Code: | 711198505 |
| Phone Number: | 3186313792 |
| Fax Number: | |
| NPI Enumeration Date: | 05/02/2008 |
| NPI Last Update Date: | 05/02/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 171000000X |
| License Number: | 2176 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | LA |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Military Health Care Provider |
| Taxonomy Specialization: | |
| Taxonomy Definition: | Active duty military health care providers not otherwise classified who need to be separately identified for operational, clinical, or administrative processes. |