Provider Demographics
NPI:1558502153
Name:WISE, MARY FELICIA (NP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:FELICIA
Last Name:WISE
Suffix:
Gender:F
Credentials:NP
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Other - First Name:
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Mailing Address - Street 1:2555 N MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2709
Mailing Address - Country:US
Mailing Address - Phone:414-267-2641
Mailing Address - Fax:
Practice Address - Street 1:2555 N MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2709
Practice Address - Country:US
Practice Address - Phone:414-372-8080
Practice Address - Fax:414-562-8084
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI164441-30163W00000X
WI10008-33363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100104639Medicaid