Provider Demographics
NPI:1407373129
Name:WISEMAN, CHEVON MARIE
Entity Type:Individual
Prefix:
First Name:CHEVON
Middle Name:MARIE
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHEVON
Other - Middle Name:MARIE
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2835 JARED PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-5005
Mailing Address - Country:US
Mailing Address - Phone:614-260-8686
Mailing Address - Fax:
Practice Address - Street 1:2835 JARED PL
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219
Practice Address - Country:US
Practice Address - Phone:614-260-8686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374920980795376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide