Healthcare Provider Details

I. General information

NPI: 1356266407
Provider Name (Legal Business Name): GENETTE JILL WISE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 N COLLEGE ST
MOUNTAIN HOME AR
72653-2406
US

IV. Provider business mailing address

171 HARLIN DR
GAINESVILLE MO
65655-7383
US

V. Phone/Fax

Practice location:
  • Phone: 870-425-1251
  • Fax: 870-425-1264
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2015039976
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: