Healthcare Provider Details

I. General information

NPI: 1568839355
Provider Name (Legal Business Name): JENNIFER WISHTISCHIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 11/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 N MAIN ST
PROVIDENCE RI
02904-5757
US

IV. Provider business mailing address

528 N MAIN ST
PROVIDENCE RI
02904-5757
US

V. Phone/Fax

Practice location:
  • Phone: 401-528-0123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberAPRN00717
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: