Provider Demographics
NPI:1407203110
Name:WISE, GYLA ANN (ARNP)
Entity Type:Individual
Prefix:
First Name:GYLA
Middle Name:ANN
Last Name:WISE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:GYLA
Other - Middle Name:ANN
Other - Last Name:VAN PATTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:402 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:IMMOKALEE
Mailing Address - State:FL
Mailing Address - Zip Code:34142-3933
Mailing Address - Country:US
Mailing Address - Phone:239-658-3560
Mailing Address - Fax:239-658-3571
Practice Address - Street 1:402 W MAIN ST
Practice Address - Street 2:
Practice Address - City:IMMOKALEE
Practice Address - State:FL
Practice Address - Zip Code:34142-3933
Practice Address - Country:US
Practice Address - Phone:239-658-3560
Practice Address - Fax:239-658-3571
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1217282363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily