Healthcare Provider Details

I. General information

NPI: 1427911940
Provider Name (Legal Business Name): LAUREN ELIZABETH WISE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST
PHILADELPHIA PA
19104-4238
US

IV. Provider business mailing address

1001 S BROAD ST APT W0510
PHILADELPHIA PA
19147-3648
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-4400
  • Fax:
Mailing address:
  • Phone: 267-885-5395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberSP034099
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: