Provider Demographics
NPI:1942261466
Name:WISE, MICHELLE T (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:T
Last Name:WISE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 S SECOND ST
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23664-1407
Mailing Address - Country:US
Mailing Address - Phone:757-713-9465
Mailing Address - Fax:
Practice Address - Street 1:680 OYSTER POINT RD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4570
Practice Address - Country:US
Practice Address - Phone:757-668-4851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001156324163WL0100X
VA0024156324363LN0005X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1946661466Medicaid