Provider Demographics
NPI:1376275578
Name:WISE, ANDREA SHAWN (AGACNP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:SHAWN
Last Name:WISE
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:DRE
Other - Middle Name:SHAWN
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AGACNP
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:200 E CHESTNUT ST STE 303
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1831
Practice Address - Country:US
Practice Address - Phone:502-629-5552
Practice Address - Fax:502-629-3132
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017990363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care