Healthcare Provider Details

I. General information

NPI: 1669865911
Provider Name (Legal Business Name): STEPHANIE POLING WISE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL VILLAGE DR SUITE 258
EDGEWOOD KY
41017-5401
US

IV. Provider business mailing address

20 MEDICAL VILLAGE DR SUITE 258
EDGEWOOD KY
41017-5401
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-2211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3009532
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: