Healthcare Provider Details

I. General information

NPI: 1487795456
Provider Name (Legal Business Name): CHRISTINE M WISE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2007
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10411 W 52ND CIR
SHAWNEE KS
66203-1811
US

IV. Provider business mailing address

10411 W 52ND CIR
SHAWNEE KS
66203-1811
US

V. Phone/Fax

Practice location:
  • Phone: 913-636-4409
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number2005023703
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number17-01026
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: