Basic Information
| Provider Information | |||||||||
| NPI: | 1437134293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILEY | ||||||||
| FirstName: | KRISTIANE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CNS,MS,APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1580 SANTA BARBARA BLVD | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321596827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522592159 | ||||||||
| FaxNumber: | 3522595731 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 WOODLAKE DR SE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559045530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072062570 | ||||||||
| FaxNumber: | 6514317758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 06/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 1400-033 | WI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 364S00000X | APRN9363537 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 364SP0813X | 1400-033 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Geropsychiatric |
ID Information
| ID | Type | State | Issuer | Description | 42238000 | 05 | WI | MEDICAID |