Provider Demographics
NPI:1942342126
Name:WISE, IRENE MANALISAY (FNP RN)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:MANALISAY
Last Name:WISE
Suffix:
Gender:F
Credentials:FNP RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:710 N BEAVER ST
Mailing Address - Street 2:BUILDING 6
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3100
Mailing Address - Country:US
Mailing Address - Phone:928-527-4325
Mailing Address - Fax:928-527-4327
Practice Address - Street 1:710 N BEAVER ST
Practice Address - Street 2:BUILDING 6
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3100
Practice Address - Country:US
Practice Address - Phone:928-527-4325
Practice Address - Fax:928-527-4327
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZAP4241363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP4733Medicaid
AKNP4733Medicaid
P33581Medicare UPIN
MW0738849OtherDEA