Provider Demographics
NPI:1265025050
Name:WISEMIND WELLNESS, LLC
Entity Type:Organization
Organization Name:WISEMIND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DINGELDEIN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP, BC
Authorized Official - Phone:541-990-2613
Mailing Address - Street 1:P.O. BOX 33784
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3784
Mailing Address - Country:US
Mailing Address - Phone:480-359-5816
Mailing Address - Fax:833-520-1481
Practice Address - Street 1:20 E THOMAS RD STE 2200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3133
Practice Address - Country:US
Practice Address - Phone:541-990-2613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-12
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ632705Medicaid