Provider Demographics
NPI:1639555428
Name:WISE, ANNE-MARIE
Entity Type:Individual
Prefix:
First Name:ANNE-MARIE
Middle Name:
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 1:120 MINEOLA BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4064
Mailing Address - Country:US
Mailing Address - Phone:516-663-6925
Mailing Address - Fax:516-663-4821
Practice Address - Street 1:120 MINEOLA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4064
Practice Address - Country:US
Practice Address - Phone:516-663-6925
Practice Address - Fax:516-663-4821
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-04
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY421221363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health