Provider Demographics
NPI:1811612401
Name:WISE, KRISTIN RAE
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:RAE
Last Name:WISE
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 1:1349 MILLS OF MIAMI BLVD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-1572
Mailing Address - Country:US
Mailing Address - Phone:502-724-5868
Mailing Address - Fax:
Practice Address - Street 1:1349 MILLS OF MIAMI BLVD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-1572
Practice Address - Country:US
Practice Address - Phone:502-724-5868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0031908363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily