Healthcare Provider Details

I. General information

NPI: 1114753845
Provider Name (Legal Business Name): SHAWNA MICHELE WISDOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHAWNA MICHELE PAGE

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 MAJOR AVE
RIVERTON WY
82501-2342
US

IV. Provider business mailing address

146 LEFT HAND DITCH RD
RIVERTON WY
82501-9135
US

V. Phone/Fax

Practice location:
  • Phone: 307-856-6587
  • Fax: 833-825-6587
Mailing address:
  • Phone: 307-855-9219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: