Provider Demographics
NPI:1093423386
Name:WISE, CRYSTAL LEA (RN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEA
Last Name:WISE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SANDY AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-1020
Mailing Address - Country:US
Mailing Address - Phone:304-231-4115
Mailing Address - Fax:304-221-3013
Practice Address - Street 1:100 TELETECH DR STE 1
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-2790
Practice Address - Country:US
Practice Address - Phone:304-231-4115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV76436163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health