=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568926731
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY WISEMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2019
-----------------------------------------------------
Last Update Date | 01/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 JAMES ST
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62439-2027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-943-3444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 IL RT 15
-----------------------------------------------------
City | ALBION
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------