Provider Demographics
NPI:1558603977
Name:WISE, SHANNON PAIGE (CNM)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:PAIGE
Last Name:WISE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4660 KENMORE AVE STE 902
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1306
Mailing Address - Country:US
Mailing Address - Phone:703-370-4300
Mailing Address - Fax:703-370-1683
Practice Address - Street 1:4660 KENMORE AVE STE 902
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1306
Practice Address - Country:US
Practice Address - Phone:703-370-4300
Practice Address - Fax:703-370-1683
Is Sole Proprietor?:No
Enumeration Date:2013-03-24
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170771367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife