Provider Demographics
NPI:1861726820
Name:WISE, JANET L
Entity type:Individual
Prefix:MISS
First Name:JANET
Middle Name:L
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 22ND ST
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-5512
Mailing Address - Country:US
Mailing Address - Phone:561-845-6223
Mailing Address - Fax:561-845-6223
Practice Address - Street 1:120 W 22ND ST
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-5512
Practice Address - Country:US
Practice Address - Phone:561-845-6223
Practice Address - Fax:561-845-6223
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11586310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility