Provider Demographics
NPI:1306219688
Name:WISEMAN, CAROLINE CANNON (NP-C)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:CANNON
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:CROLINE
Other - Middle Name:MURRAY
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10110 MOLECULAR DR STE 206
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-7542
Mailing Address - Country:US
Mailing Address - Phone:301-279-2779
Mailing Address - Fax:240-403-0190
Practice Address - Street 1:10110 MOLECULAR DR STE 206
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-7542
Practice Address - Country:US
Practice Address - Phone:301-279-2779
Practice Address - Fax:240-403-0190
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1016495363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology