Provider Demographics
NPI:1720545213
Name:WISE, ALLISON NANCE (PTA)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:NANCE
Last Name:WISE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:REBECCA
Other - Last Name:NANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28782 CANTON RD APT A
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-8155
Mailing Address - Country:US
Mailing Address - Phone:704-984-2778
Mailing Address - Fax:
Practice Address - Street 1:2000 W MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-5446
Practice Address - Country:US
Practice Address - Phone:704-984-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA6508225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1720545213Medicaid