Provider Demographics
NPI:1952438665
Name:WISENER, CLARA DENISE (LMP)
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:DENISE
Last Name:WISENER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:WA
Mailing Address - Zip Code:99166-0312
Mailing Address - Country:US
Mailing Address - Phone:509-775-0233
Mailing Address - Fax:509-775-8029
Practice Address - Street 1:720 S CLARK AVE
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:WA
Practice Address - Zip Code:99166
Practice Address - Country:US
Practice Address - Phone:509-775-0233
Practice Address - Fax:509-775-8029
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017276225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist