Healthcare Provider Details

I. General information

NPI: 1558502153
Provider Name (Legal Business Name): MARY FELICIA WISE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 N MARTIN LUTHER KING DR
MILWAUKEE WI
53212-2709
US

IV. Provider business mailing address

2555 N MARTIN LUTHER KING DR
MILWAUKEE WI
53212-2709
US

V. Phone/Fax

Practice location:
  • Phone: 414-372-8080
  • Fax: 414-562-8084
Mailing address:
  • Phone: 414-267-2641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number164441-30
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10008-33
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number10008-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: