Provider Demographics
NPI:1033447594
Name:WISE WOMAN WELLNESS LLC
Entity Type:Organization
Organization Name:WISE WOMAN WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RANDI
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:920-339-5252
Mailing Address - Street 1:1480 SWAN RD
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7966
Mailing Address - Country:US
Mailing Address - Phone:920-339-5252
Mailing Address - Fax:920-632-7652
Practice Address - Street 1:1480 SWAN RD
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-7966
Practice Address - Country:US
Practice Address - Phone:920-339-5252
Practice Address - Fax:920-632-7652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI115-030363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1427016609OtherNPI
WI1427016609OtherNPI