Provider Demographics
NPI:1336883933
Name:WISINSKI, JEANA RAE
Entity Type:Individual
Prefix:
First Name:JEANA
Middle Name:RAE
Last Name:WISINSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11800 SANDY BOTTOM RD NE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-9353
Mailing Address - Country:US
Mailing Address - Phone:616-443-3839
Mailing Address - Fax:
Practice Address - Street 1:11800 SANDY BOTTOM RD NE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-9353
Practice Address - Country:US
Practice Address - Phone:616-443-3839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704230821NSA2206N364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist