Provider Demographics
NPI:1871259374
Name:WISE, SARA L
Entity type:Individual
Prefix:
First Name:SARA
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 1:68 WOMMACK AVE
Mailing Address - Street 2:
Mailing Address - City:SOPERTON
Mailing Address - State:GA
Mailing Address - Zip Code:30457-2301
Mailing Address - Country:US
Mailing Address - Phone:478-595-0060
Mailing Address - Fax:
Practice Address - Street 1:68 WOMMACK AVE
Practice Address - Street 2:
Practice Address - City:SOPERTON
Practice Address - State:GA
Practice Address - Zip Code:30457-2301
Practice Address - Country:US
Practice Address - Phone:478-595-0060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide