Provider Demographics
NPI:1114753845
Name:WISDOM, SHAWNA MICHELE
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:MICHELE
Last Name:WISDOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:MICHELE
Other - Last Name:PAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:146 LEFT HAND DITCH RD
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-9135
Mailing Address - Country:US
Mailing Address - Phone:307-855-9219
Mailing Address - Fax:
Practice Address - Street 1:1110 MAJOR AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2342
Practice Address - Country:US
Practice Address - Phone:307-856-6587
Practice Address - Fax:833-825-6587
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator