Healthcare Provider Details

I. General information

NPI: 1558005140
Provider Name (Legal Business Name): KAITLYN JANAE MCCOLLUM WISE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAITLYN JANAE MCCOLLUM

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE # MLC9016
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3333 BURNET AVE # MLC9016
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-803-4829
  • Fax: 513-803-9244
Mailing address:
  • Phone: 513-803-4829
  • Fax: 513-803-9244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.152748
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: