Provider Demographics
NPI:1003558354
Name:WISE, VICTORIA LAUREN
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LAUREN
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 N 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:PINCONNING
Mailing Address - State:MI
Mailing Address - Zip Code:48650-7976
Mailing Address - Country:US
Mailing Address - Phone:989-313-3069
Mailing Address - Fax:
Practice Address - Street 1:4320 N 11 MILE RD
Practice Address - Street 2:
Practice Address - City:PINCONNING
Practice Address - State:MI
Practice Address - Zip Code:48650-7976
Practice Address - Country:US
Practice Address - Phone:989-313-3069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-08
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374700000XNursing Service Related ProvidersTechnician