Provider Demographics
NPI:1942217393
Name:WISE, KISHA NICHELLA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KISHA
Middle Name:NICHELLA
Last Name:WISE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 MADELINE CIR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-3527
Mailing Address - Country:US
Mailing Address - Phone:770-339-8057
Mailing Address - Fax:770-339-8068
Practice Address - Street 1:370 MADELINE CIR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-3527
Practice Address - Country:US
Practice Address - Phone:770-339-8057
Practice Address - Fax:770-339-8068
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN071397164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse