Provider Demographics
NPI:1861825283
Name:WISE, GARY LEE (LPN)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:LEE
Last Name:WISE
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-1575
Mailing Address - Country:US
Mailing Address - Phone:330-573-1761
Mailing Address - Fax:
Practice Address - Street 1:276 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-1575
Practice Address - Country:US
Practice Address - Phone:330-573-1761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.099163-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse