Healthcare Provider Details

I. General information

NPI: 1952871717
Provider Name (Legal Business Name): AMANDA BETH WISECUP CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA B WERLING CRNA

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 SOUTHERN BLVD
KETTERING OH
45429-1221
US

IV. Provider business mailing address

102 CANTERBURY DR
DAYTON OH
45429-1402
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-8228
  • Fax: 937-293-8229
Mailing address:
  • Phone: 937-459-7428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.019806
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: