Healthcare Provider Details

I. General information

NPI: 1255791802
Provider Name (Legal Business Name): KIM A WISE-GASTINELL PLPC, AD.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIM A WISE

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 WRIGHT AVE
CROWLEY LA
70526-2226
US

IV. Provider business mailing address

622 RIVERSIDE DR
MONROE LA
71201-6211
US

V. Phone/Fax

Practice location:
  • Phone: 225-476-3809
  • Fax:
Mailing address:
  • Phone: 318-282-7809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPLC9874
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: