Healthcare Provider Details

I. General information

NPI: 1902443757
Provider Name (Legal Business Name): MICHELE WEIDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1449 CREEKSIDE DR APT 1055
WALNUT CREEK CA
94596-5692
US

IV. Provider business mailing address

1449 CREEKSIDE DR APT 1055
WALNUT CREEK CA
94596-5692
US

V. Phone/Fax

Practice location:
  • Phone: 707-373-2578
  • Fax:
Mailing address:
  • Phone: 707-373-2578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number664103
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: