Provider Demographics
NPI:1609209014
Name:WISE, MELANIE K (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:K
Last Name:WISE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7763 NORTHSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29420
Mailing Address - Country:US
Mailing Address - Phone:843-818-1496
Mailing Address - Fax:
Practice Address - Street 1:7763 NORTHSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420
Practice Address - Country:US
Practice Address - Phone:843-818-1496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPN16853164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse