Provider Demographics
NPI:1588270599
Name:WISE, KIMBERLY (RN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 LYNN HAVEN LN
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-3410
Mailing Address - Country:US
Mailing Address - Phone:314-619-6015
Mailing Address - Fax:
Practice Address - Street 1:14561 N OUTER 40 RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5703
Practice Address - Country:US
Practice Address - Phone:314-881-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007012742163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse