Healthcare Provider Details

I. General information

NPI: 1164699690
Provider Name (Legal Business Name): ANNIE WISE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1281 W TUNNEL BLVD
HOUMA LA
70360-2794
US

IV. Provider business mailing address

1281 W TUNNEL BLVD
HOUMA LA
70360-2794
US

V. Phone/Fax

Practice location:
  • Phone: 985-876-2321
  • Fax: 985-917-0808
Mailing address:
  • Phone: 985-876-2321
  • Fax: 985-917-0808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License NumberAP03922
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: