Healthcare Provider Details

I. General information

NPI: 1942342126
Provider Name (Legal Business Name): IRENE MANALISAY WISE FNP RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 N BEAVER ST BUILDING 6
FLAGSTAFF AZ
86001-3100
US

IV. Provider business mailing address

710 N BEAVER ST BUILDING 6
FLAGSTAFF AZ
86001-3100
US

V. Phone/Fax

Practice location:
  • Phone: 928-527-4325
  • Fax: 928-527-4327
Mailing address:
  • Phone: 928-527-4325
  • Fax: 928-527-4327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP4241
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: