Provider Demographics
NPI:1568148682
Name:WISE, COURTNEY LEEANN (PRS)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEEANN
Last Name:WISE
Suffix:
Gender:F
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 BLOOMINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:FEDERALSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21632-1012
Mailing Address - Country:US
Mailing Address - Phone:410-754-9021
Mailing Address - Fax:833-908-2285
Practice Address - Street 1:215 BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:FEDERALSBURG
Practice Address - State:MD
Practice Address - Zip Code:21632-1012
Practice Address - Country:US
Practice Address - Phone:410-754-9021
Practice Address - Fax:833-908-2285
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist