Healthcare Provider Details

I. General information

NPI: 1881682482
Provider Name (Legal Business Name): MARILYN J WISEMAN MSN, CRNP,CRNFA,CNOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 04/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19415 DEERFIELD AVE SUITE 112
LANSDOWNE VA
20176-8452
US

IV. Provider business mailing address

14636 CHAPEL LN
LEESBURG VA
20176-5276
US

V. Phone/Fax

Practice location:
  • Phone: 703-724-1195
  • Fax: 703-724-4495
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAC000186
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024165343
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: