Healthcare Provider Details

I. General information

NPI: 1184047565
Provider Name (Legal Business Name): MARY ELIZABETH WISE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 01/04/2022
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

496 FAIRFIELD CT
EVANS GA
30809-3641
US

IV. Provider business mailing address

3647 J DEWEY GRAY CIR STE 200
AUGUSTA GA
30909-2205
US

V. Phone/Fax

Practice location:
  • Phone: 229-292-9248
  • Fax:
Mailing address:
  • Phone: 706-504-9712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN213344
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN213344
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: