Healthcare Provider Details

I. General information

NPI: 1447559802
Provider Name (Legal Business Name): DANIELLE N WIESE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANIELLE C NOEL

II. Dates (important events)

Enumeration Date: 03/23/2011
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 W OAK ST SUITE 210
ZIONSVILLE IN
46077-1962
US

IV. Provider business mailing address

250 N SHADELAND AVE SUITE 130
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-873-8855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01073742A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: