Provider Demographics
NPI:1194104414
Name:WISTER, ANNE
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:WISTER
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 1:102 SERENITY DR
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:FL
Mailing Address - Zip Code:32666-3032
Mailing Address - Country:US
Mailing Address - Phone:727-251-2324
Mailing Address - Fax:
Practice Address - Street 1:102 SERENITY DR
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:FL
Practice Address - Zip Code:32666-3032
Practice Address - Country:US
Practice Address - Phone:727-251-2324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA43454174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist