Provider Demographics
NPI:1881682482
Name:WISEMAN, MARILYN J (MSN, CRNP,CRNFA,CNOR)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:J
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:MSN, CRNP,CRNFA,CNOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14636 CHAPEL LN
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-5276
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19415 DEERFIELD AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8452
Practice Address - Country:US
Practice Address - Phone:703-724-1195
Practice Address - Fax:703-724-4495
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2009-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC000186363LF0000X
VA0024165343363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAMC11979Medicare PIN