Provider Demographics
NPI:1215461298
Name:WISE, SHARON RENEE (LPN, CDCA)
Entity type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:RENEE
Last Name:WISE
Suffix:
Gender:F
Credentials:LPN, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5818 COUNTY ROAD 93
Mailing Address - Street 2:
Mailing Address - City:MOUNT GILEAD
Mailing Address - State:OH
Mailing Address - Zip Code:43338-9684
Mailing Address - Country:US
Mailing Address - Phone:567-241-8299
Mailing Address - Fax:
Practice Address - Street 1:8402 BLACKJACK RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-9193
Practice Address - Country:US
Practice Address - Phone:740-397-0442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH160873101YA0400X
171M00000X
OHPN-090990164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator