1275831406 NPI number — MRS. MYSTIE-DAWN RAYMOND WISE CNMT

Table of content: MRS. MYSTIE-DAWN RAYMOND WISE CNMT (NPI 1275831406)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275831406 NPI number — MRS. MYSTIE-DAWN RAYMOND WISE CNMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISE
Provider First Name:
MYSTIE-DAWN
Provider Middle Name:
RAYMOND
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275831406
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5589 S CURTICE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLETON
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80120-1105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-795-4379
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3955 E EXPOSITION AVE
Provider Second Line Business Practice Location Address:
STE. #320
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80209-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-777-1151
Provider Business Practice Location Address Fax Number:
303-777-3112
Provider Enumeration Date:
03/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  7836 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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