Provider Demographics
NPI:1205461514
Name:WISE, GRETCHEN (RN)
Entity type:Individual
Prefix:
First Name:GRETCHEN
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 1:320 ALPENGLOW LN
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-8506
Mailing Address - Country:US
Mailing Address - Phone:610-212-6936
Mailing Address - Fax:
Practice Address - Street 1:320 ALPENGLOW LN
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-8506
Practice Address - Country:US
Practice Address - Phone:406-222-3541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT127586163W00000X
MT158939363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT127586OtherMT BON