Healthcare Provider Details

I. General information

NPI: 1528970613
Provider Name (Legal Business Name): ALEXIS NICOLE WISE OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 SPOTSYLVANIA PKWY
FREDERICKSBURG VA
22407-9433
US

IV. Provider business mailing address

3416 GAYTON MEADOWS TER
RICHMOND VA
23233-6647
US

V. Phone/Fax

Practice location:
  • Phone: 540-479-4779
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number0119011595
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: