MEDICARE: JESSICA DANIELLE KEALA WISE DNP, CNM, PMHNP

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	5020240	NC
2	367A00000X	Advanced Practice Midwife

General Provider Information

NPI Number	:	1912413428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA DANIELLE KEALA WISE DNP, CNM, PMHNP

Provider Business Mailing Address
First Line	:	4412 PARK RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3130
Country	:	US
Telephone Number	:	617-379-0496
Fax Number	:

Provider Business Practice Location Address
First Line	:	4412 PARK RD STE B
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3130
Country	:	US
Telephone Number	:	617-379-0496
Fax Number	:

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

Provider Enumeration Date	:	12/19/2017
Last Update Date	:	02/10/2026

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