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General NPI Number Information
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NPI Number | 1063711869
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Entity Type | Individual
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Provider Name | MS. JOANNA ELISE WIESE
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Gender | Female
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Dates
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Enumeration Date | 03/18/2011
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Last Update Date | 10/16/2025
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Provider Practice Location Address
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Address Line | 90 HOPE DR BLDG 6000
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City | MOUNTAIN HOME AFB
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State | ID
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Zip | 83648-1062
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Country | US
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Telephone | 208-828-7581
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Fax |
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Provider Business Mailing Address
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Address Line | 9169 W STATE ST STE 725
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City | BOISE
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State | ID
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Zip | 83714-1733
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Country | US
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Telephone | 208-828-7581
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TP0016X
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Taxonomy Name | Prescribing (Medical) Psychologist
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License Number | 203430
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License Number State | ID
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