Provider Demographics
NPI:1982683488
Name:WISE, DEENA RENAE (DO)
Entity type:Individual
Prefix:DR
First Name:DEENA
Middle Name:RENAE
Last Name:WISE
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:DEENA
Other - Middle Name:RENAE
Other - Last Name:WALDEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1738 WREN WAY
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-7102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1514 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4131
Practice Address - Country:US
Practice Address - Phone:770-845-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002008852208000000X
FLOS15511208000000X, 208M00000X
OK3820208000000X
KY05305208000000X
NC2020-03433208000000X
GA86763208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100877500Medicaid
OKOK400892Medicare PIN
H57860Medicare UPIN