Provider Demographics
NPI:1376750737
Name:WISE, JOANN (CARE COORDINATOR)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:CARE COORDINATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 DRAKE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4481
Mailing Address - Country:US
Mailing Address - Phone:907-274-5258
Mailing Address - Fax:907-274-0101
Practice Address - Street 1:2915 DRAKE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4481
Practice Address - Country:US
Practice Address - Phone:907-274-5258
Practice Address - Fax:907-274-0101
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM44221Medicaid