Provider Demographics
NPI:1992218929
Name:WISE, COURTNEY JANA (LPN)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:JANA
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 1:32 RUTGERS DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-3087
Mailing Address - Country:US
Mailing Address - Phone:908-636-1258
Mailing Address - Fax:
Practice Address - Street 1:32 RUTGERS DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-3087
Practice Address - Country:US
Practice Address - Phone:908-636-1258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY325202-10164W00000X
NJ26NP07273800164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse