Provider Demographics
NPI:1134340599
Name:WISE, DEBORAH ANN (CNS)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:ANN
Last Name:WISE
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 SOUTHERN BLVD STE 401
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1265
Mailing Address - Country:US
Mailing Address - Phone:855-500-2873
Mailing Address - Fax:937-281-3913
Practice Address - Street 1:3700 SOUTHERN BLVD STE 401
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1226
Practice Address - Country:US
Practice Address - Phone:855-500-2873
Practice Address - Fax:937-281-3913
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN167460163WX0200X
OHCOA02210NS364S00000X, 364SX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology
No163WX0200XNursing Service ProvidersRegistered NurseOncology
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067949Medicaid
OHH099391Medicare PIN