Provider Demographics
NPI:1417573106
Name:WISEN, DANIELLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:
Last Name:WISEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35007 S TURTLE TRL APT B
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4261
Mailing Address - Country:US
Mailing Address - Phone:440-622-4587
Mailing Address - Fax:
Practice Address - Street 1:35007 S TURTLE TRL APT B
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4261
Practice Address - Country:US
Practice Address - Phone:440-622-4587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant