Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife |
NPI | 1134411788 |
---|---|
Provider Name | Mrs. Kimberly Tai Wise |
First Address | Lebanon, OR 97355-4422 |
Second Address | Lebanon, OR 97355-4422 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/05/2011 |
Last Update Date | 13/05/2011 |