Provider Demographics
NPI:1609263029
Name:WISE, NOVA DEERE
Entity Type:Individual
Prefix:
First Name:NOVA
Middle Name:DEERE
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104037 N 3840 RD
Mailing Address - Street 2:
Mailing Address - City:OKEMAH
Mailing Address - State:OK
Mailing Address - Zip Code:74859-3832
Mailing Address - Country:US
Mailing Address - Phone:918-268-4738
Mailing Address - Fax:
Practice Address - Street 1:104037 N 3840 RD
Practice Address - Street 2:
Practice Address - City:OKEMAH
Practice Address - State:OK
Practice Address - Zip Code:74859-3832
Practice Address - Country:US
Practice Address - Phone:918-268-4738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator