Healthcare Provider Details

I. General information

NPI: 1720230873
Provider Name (Legal Business Name): KIMBERLY SUE WIEGAND CFM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 N CENTER ST RTE 159
MARYVILLE IL
62062-5624
US

IV. Provider business mailing address

2700 N CENTER ST RTE 159
MARYVILLE IL
62062-5624
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-7474
  • Fax: 618-288-7037
Mailing address:
  • Phone: 618-288-7474
  • Fax: 618-288-7037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number049-177617
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberCFM01697
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number95212
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: