Provider Demographics
NPI:1427318435
Name:WISE, KATIE A (CD, ERYT, CYPT)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:A
Last Name:WISE
Suffix:
Gender:F
Credentials:CD, ERYT, CYPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 29TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2317
Mailing Address - Country:US
Mailing Address - Phone:303-815-5284
Mailing Address - Fax:
Practice Address - Street 1:737 29TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2317
Practice Address - Country:US
Practice Address - Phone:303-815-5284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator