Provider Demographics
NPI:1619090990
Name:WISDOM, JANICE REYNOLDS (PT)
Entity Type:Individual
Prefix:MS
First Name:JANICE
Middle Name:REYNOLDS
Last Name:WISDOM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4357 SAVANNAH LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-7999
Mailing Address - Country:US
Mailing Address - Phone:479-872-0383
Mailing Address - Fax:
Practice Address - Street 1:4357 SAVANNAH LN
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-7999
Practice Address - Country:US
Practice Address - Phone:479-872-0383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2328174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist