Provider Demographics
NPI:1467027110
Name:WISE, AMBER NICOLE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:AMBER
Middle Name:NICOLE
Last Name:WISE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BOYSENBERRY LN
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32124-3658
Mailing Address - Country:US
Mailing Address - Phone:229-220-6537
Mailing Address - Fax:
Practice Address - Street 1:1075 MASON AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117
Practice Address - Country:US
Practice Address - Phone:386-255-4596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115803500Medicaid