Provider Demographics
NPI:1801800867
Name:WISEMAN, BONITA E (FNP)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:E
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-1753
Mailing Address - Country:US
Mailing Address - Phone:931-526-1688
Mailing Address - Fax:931-372-0234
Practice Address - Street 1:201 W 5TH ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-1753
Practice Address - Country:US
Practice Address - Phone:931-526-1688
Practice Address - Fax:931-372-0234
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6950363LF0000X
TNRN0000098800363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3342652Medicare ID - Type Unspecified
TN33426521Medicare PIN