Provider Demographics
NPI:1386234607
Name:WISE, LAVONA ANGELA
Entity type:Individual
Prefix:
First Name:LAVONA
Middle Name:ANGELA
Last Name:WISE
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 1:28925 GLENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-1625
Mailing Address - Country:US
Mailing Address - Phone:313-461-8691
Mailing Address - Fax:
Practice Address - Street 1:28925 GLENWOOD ST
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141
Practice Address - Country:US
Practice Address - Phone:313-461-8691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No251E00000XAgenciesHome Health