Provider Demographics
NPI:1881185395
Name:WISEMAN, LINNEL KENNETH
Entity Type:Individual
Prefix:
First Name:LINNEL
Middle Name:KENNETH
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 MARYLAND AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-4401
Mailing Address - Country:US
Mailing Address - Phone:202-817-1057
Mailing Address - Fax:
Practice Address - Street 1:1302 MARYLAND AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4401
Practice Address - Country:US
Practice Address - Phone:202-817-1057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC$$$$$$$$$Medicaid