Provider Demographics
NPI:1609115773
Name:WISE, JACQUELINE NICOLE (ARNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:WISE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 NATCHEZ TRACE AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7995
Mailing Address - Country:US
Mailing Address - Phone:270-783-3573
Mailing Address - Fax:270-783-4081
Practice Address - Street 1:225 NATCHEZ TRACE AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7995
Practice Address - Country:US
Practice Address - Phone:270-783-3573
Practice Address - Fax:270-783-4081
Is Sole Proprietor?:No
Enumeration Date:2013-02-08
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007899363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily