Provider Demographics
NPI:1033983747
Name:WISE, TIOMBE E (CHW)
Entity Type:Individual
Prefix:
First Name:TIOMBE
Middle Name:E
Last Name:WISE
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:TIOMBE
Other - Middle Name:E
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CHW
Mailing Address - Street 1:1365 CRAFTON AVE APT 2109
Mailing Address - Street 2:
Mailing Address - City:MENTONE
Mailing Address - State:CA
Mailing Address - Zip Code:92359-1355
Mailing Address - Country:US
Mailing Address - Phone:909-235-2924
Mailing Address - Fax:
Practice Address - Street 1:1365 CRAFTON AVE APT 2109
Practice Address - Street 2:
Practice Address - City:MENTONE
Practice Address - State:CA
Practice Address - Zip Code:92359-1355
Practice Address - Country:US
Practice Address - Phone:909-235-2924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker