Healthcare Provider Details

I. General information

NPI: 1134340599
Provider Name (Legal Business Name): DEBORAH ANN WISE CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 SOUTHERN BLVD STE 401
KETTERING OH
45429-1226
US

IV. Provider business mailing address

3700 SOUTHERN BLVD STE 401
KETTERING OH
45429-1265
US

V. Phone/Fax

Practice location:
  • Phone: 855-500-2873
  • Fax: 937-281-3913
Mailing address:
  • Phone: 855-500-2873
  • Fax: 937-281-3913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberRN167460
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberCOA02210NS
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code364SX0200X
TaxonomyOncology Clinical Nurse Specialist
License NumberCOA02210NS
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: