MEDICARE: RENAE LYNN WISE PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	C-APN.0001492-C-NP	CO

General Provider Information

NPI Number	:	1881259224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENAE LYNN WISE PMHNP-BC

Provider Business Mailing Address
First Line	:	630 SOUTHPOINTE CT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3896
Country	:	US
Telephone Number	:	719-289-3173
Fax Number	:	866-718-1677

Provider Business Practice Location Address
First Line	:	630 SOUTHPOINTE CT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3896
Country	:	US
Telephone Number	:	719-289-3173
Fax Number	:	866-718-1677

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2019
Last Update Date	:	05/01/2019

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