Healthcare Provider Details

I. General information

NPI: 1093190324
Provider Name (Legal Business Name): ANGELA WEIDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 04/26/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 E MAPLE ST
GILLESPIE IL
62033-1473
US

IV. Provider business mailing address

109 E MAPLE ST
GILLESPIE IL
62033-1473
US

V. Phone/Fax

Practice location:
  • Phone: 217-839-4190
  • Fax: 217-839-1538
Mailing address:
  • Phone: 217-839-4190
  • Fax: 217-839-1538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number041.389054
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: