Provider Demographics
NPI:1174389340
Name:WISMER, STEPHANIE (FNP-BC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WISMER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 LEIVASY RD
Mailing Address - Street 2:
Mailing Address - City:NETTIE
Mailing Address - State:WV
Mailing Address - Zip Code:26681-4158
Mailing Address - Country:US
Mailing Address - Phone:304-880-8836
Mailing Address - Fax:
Practice Address - Street 1:71 AVENUE A
Practice Address - Street 2:
Practice Address - City:RICHWOOD
Practice Address - State:WV
Practice Address - Zip Code:26261-1204
Practice Address - Country:US
Practice Address - Phone:304-846-2608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV118356363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily