Provider Demographics
NPI:1851844831
Name:WISE, VIN NICOLE (MASTER'S)
Entity Type:Individual
Prefix:MRS
First Name:VIN
Middle Name:NICOLE
Last Name:WISE
Suffix:
Gender:F
Credentials:MASTER'S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 ARROYO SECO
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-7796
Mailing Address - Country:US
Mailing Address - Phone:575-551-1780
Mailing Address - Fax:
Practice Address - Street 1:904 ARROYO SECO
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-7796
Practice Address - Country:US
Practice Address - Phone:575-551-1780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist