=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851782965
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOUISE WISE DNP, PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2015
-----------------------------------------------------
Last Update Date | 01/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2206 HANFRED LN STE 103
-----------------------------------------------------
City | TUCKER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30084-4809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-831-6429
-----------------------------------------------------
Fax | 678-669-2848
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 309
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30021-0309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN-NP211259
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | AC003029
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------