MEDICARE: INDIA NICOLE WISEMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2355S0801X	Speech-Language Assistant	41818	TX

General Provider Information

NPI Number	:	1881263671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	INDIA NICOLE WISEMAN

Provider Business Mailing Address
First Line	:	13504 SCHROEDER RD APT 1305
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-3651
Country	:	US
Telephone Number	:	346-405-0404
Fax Number	:

Provider Business Practice Location Address
First Line	:	17314 TOMBALL PKWY STE 230
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77064-1140
Country	:	US
Telephone Number	:	832-895-3400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2021
Last Update Date	:	06/24/2021

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Directions to “ INDIA NICOLE WISEMAN ” Practice Location

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