Provider Demographics
NPI:1609926047
Name:WISE, ELIZABETH HILLERY (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:HILLERY
Last Name:WISE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:401 E CHESTNUT ST
Practice Address - Street 2:SUITE 510
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-5700
Practice Address - Country:US
Practice Address - Phone:502-588-4800
Practice Address - Fax:502-588-4801
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004329363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100246450Medicaid
IN201179160Medicaid