Provider Demographics
NPI:1073922068
Name:WISEMAN, HOLLY (CLC)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36500 WOODINGHAM ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-1688
Mailing Address - Country:US
Mailing Address - Phone:586-930-2438
Mailing Address - Fax:
Practice Address - Street 1:36500 WOODINGHAM ST
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-1688
Practice Address - Country:US
Practice Address - Phone:586-930-2438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIALPP-205479174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN