Provider Demographics
NPI:1245047661
Name:WISE, KYRA L (LPN)
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:L
Last Name:WISE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5026 KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:ROOTSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44272-9306
Mailing Address - Country:US
Mailing Address - Phone:330-807-8253
Mailing Address - Fax:
Practice Address - Street 1:7171 KECK PARK CIR NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-6301
Practice Address - Country:US
Practice Address - Phone:330-807-8253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.124176.MED.IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse