Healthcare Provider Details

I. General information

NPI: 1710198957
Provider Name (Legal Business Name): DR. ALLISON JANE WIESMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2007
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 W MUSKEGON DR
GREENFIELD IN
46140-3069
US

IV. Provider business mailing address

120 W MCKENZIE RD SUITE H
GREENFIELD IN
46140-3084
US

V. Phone/Fax

Practice location:
  • Phone: 317-468-6270
  • Fax: 317-468-6268
Mailing address:
  • Phone: 317-462-2335
  • Fax: 317-462-2069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11013113A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01066799A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: