Provider Demographics
NPI:1346909884
Name:WISEMAN, TAYLER MARIE
Entity Type:Individual
Prefix:
First Name:TAYLER
Middle Name:MARIE
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 TEEL BROOKE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-4000
Mailing Address - Country:US
Mailing Address - Phone:540-598-8979
Mailing Address - Fax:
Practice Address - Street 1:300 PELL AVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1134
Practice Address - Country:US
Practice Address - Phone:540-484-1456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605703225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant