Healthcare Provider Details

I. General information

NPI: 1770306979
Provider Name (Legal Business Name): BETTY NICOLE WISE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28321 MAIN ST APT 3
MILLBURY OH
43447-9486
US

IV. Provider business mailing address

28321 MAIN ST APT 3
MILLBURY OH
43447-9486
US

V. Phone/Fax

Practice location:
  • Phone: 567-208-3720
  • Fax:
Mailing address:
  • Phone: 567-208-3720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: