Provider Demographics
NPI:1356086748
Name:WISE, SHAUNA
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:WISE
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 1:156 THISTLE ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24739-5926
Mailing Address - Country:US
Mailing Address - Phone:304-952-0302
Mailing Address - Fax:
Practice Address - Street 1:156 THISTLE ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24739-5926
Practice Address - Country:US
Practice Address - Phone:304-952-0302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-01
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024184185363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily