Provider Demographics
NPI:1023905080
Name:WISE, ANN MARIE NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:ANN MARIE
Middle Name:NICOLE
Last Name:WISE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 OLYMPIC WAY APT H
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-7920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2335 VISTA WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5663
Practice Address - Country:US
Practice Address - Phone:760-547-2666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53978225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty