Provider Demographics
NPI:1881804417
Name:WISEHART, MICHELLE LEE
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEE
Last Name:WISEHART
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 1:4263 BENNINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-1747
Mailing Address - Country:US
Mailing Address - Phone:330-635-1767
Mailing Address - Fax:
Practice Address - Street 1:4263 BENNINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-1747
Practice Address - Country:US
Practice Address - Phone:330-635-1767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2524478374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide