Healthcare Provider Details

I. General information

NPI: 1871795369
Provider Name (Legal Business Name): CHRISTINE ANN WISWELL R.T.R.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 BRIAR HL
FRUITPORT MI
49415-9647
US

IV. Provider business mailing address

3400 BRIAR HL
FRUITPORT MI
49415-9647
US

V. Phone/Fax

Practice location:
  • Phone: 231-638-3078
  • Fax:
Mailing address:
  • Phone: 231-638-3078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberRRT3305
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: