Provider Demographics
NPI:1245265917
Name:WISE, ELISE CAROLYN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:CAROLYN
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 1:4425 W OLIVE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-3843
Mailing Address - Country:US
Mailing Address - Phone:623-937-9203
Mailing Address - Fax:623-930-0358
Practice Address - Street 1:4425 W OLIVE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-3843
Practice Address - Country:US
Practice Address - Phone:623-937-9203
Practice Address - Fax:623-930-0358
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3213363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP 1011OtherFAMILY NURSE PRACTITIONER
AZAP 1011OtherFAMILY NURSE PRACTITIONER