Provider Demographics
NPI:1275786451
Name:WISDOM, TERESITA C (ANRP)
Entity Type:Individual
Prefix:
First Name:TERESITA
Middle Name:C
Last Name:WISDOM
Suffix:
Gender:F
Credentials:ANRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5454 NEW CUT RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-4271
Mailing Address - Country:US
Mailing Address - Phone:502-995-2450
Mailing Address - Fax:502-995-2464
Practice Address - Street 1:9700 STONESTREET RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-2884
Practice Address - Country:US
Practice Address - Phone:502-995-2450
Practice Address - Fax:502-995-2464
Is Sole Proprietor?:No
Enumeration Date:2008-10-31
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY46780363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner