Provider Demographics
NPI:1821624982
Name:WISE, NICOLE LEE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:WISE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 FLINT ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-4021
Mailing Address - Country:US
Mailing Address - Phone:703-300-4069
Mailing Address - Fax:
Practice Address - Street 1:800 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1552
Practice Address - Country:US
Practice Address - Phone:703-300-4069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA4609208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program