Provider Demographics
NPI:1457829673
Name:WISE, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07882-1837
Mailing Address - Country:US
Mailing Address - Phone:908-268-6623
Mailing Address - Fax:
Practice Address - Street 1:6 CLUB HOUSE DR STE 102
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07882-2213
Practice Address - Country:US
Practice Address - Phone:908-237-4144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00853300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily