MEDICARE: MRS. MARILYN J WISEMAN MSN, CRNP,CRNFA,CNOR

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	363LF0000X	Family Nurse Practitioner	AC000186	MD
2	363LF0000X	Family Nurse Practitioner	0024165343	VA

General Provider Information

NPI Number	:	1881682482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARILYN J WISEMAN MSN, CRNP,CRNFA,CNOR

Provider Business Mailing Address
First Line	:	14636 CHAPEL LN
Second Line	:
City	:	LEESBURG
State	:	VA
Zip	:	20176-5276
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19415 DEERFIELD AVE
Second Line	:	SUITE 112
City	:	LANSDOWNE
State	:	VA
Zip	:	20176-8452
Country	:	US
Telephone Number	:	703-724-1195
Fax Number	:	703-724-4495

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

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	04/11/2009

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