Provider Demographics
NPI:1932638285
Name:WISE, ACQUELINE
Entity Type:Individual
Prefix:
First Name:ACQUELINE
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 E SAINT PETER ST
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-3752
Mailing Address - Country:US
Mailing Address - Phone:337-321-9204
Mailing Address - Fax:337-321-9210
Practice Address - Street 1:449 E SAINT PETER ST
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-3752
Practice Address - Country:US
Practice Address - Phone:337-321-9204
Practice Address - Fax:337-321-9210
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator