Provider Demographics
NPI:1093783193
Name:WISEMAN, MARJORIE E (NP)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:E
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3631 N MORRISON RD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5547
Mailing Address - Country:US
Mailing Address - Phone:765-281-3443
Mailing Address - Fax:
Practice Address - Street 1:3631 N MORRISON RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5547
Practice Address - Country:US
Practice Address - Phone:765-281-3443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001347A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200379350Medicaid
INP01014254OtherRR MEDICARE
INP66706Medicare UPIN
INP01014254OtherRR MEDICARE