Healthcare Provider Details

I. General information

NPI: 1972922458
Provider Name (Legal Business Name): KIMBERLY KING NELSON WEDERQUIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 10TH AVE N
FORT DODGE IA
50501-2503
US

IV. Provider business mailing address

417 10TH AVE N
FORT DODGE IA
50501-2503
US

V. Phone/Fax

Practice location:
  • Phone: 515-408-7353
  • Fax:
Mailing address:
  • Phone: 515-408-7353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number096865
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number096865
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number096865
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number096865
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number096865
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: