Individual
ANGELIQUE WISE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMT
Contact information
Practice address
14340 SW 80TH PL, TIGARD, OR 97224-8162
(971) 269-4080
Mailing address
14340 SW 80TH PL, PORTLAND, OR 97224-8162
(971) 269-4080
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
LMT#17875
OR
Other
Enumeration date
05/20/2011
Last updated
03/17/2018
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