Provider Demographics
NPI:1740019694
Name:WISNER, PHOENIX (MT)
Entity type:Individual
Prefix:
First Name:PHOENIX
Middle Name:
Last Name:WISNER
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10500 WAKEMAN DR STE 500
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-8014
Mailing Address - Country:US
Mailing Address - Phone:540-785-7888
Mailing Address - Fax:
Practice Address - Street 1:10500 WAKEMAN DR STE 500
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-8014
Practice Address - Country:US
Practice Address - Phone:540-785-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019019873225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty