Healthcare Provider Details

I. General information

NPI: 1174789010
Provider Name (Legal Business Name): DEADRA JEANNA WIEGEL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DEDE WIEGEL

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

337 S HARRISON ST
LEBANON KY
40033-1150
US

IV. Provider business mailing address

337 S HARRISON ST
LEBANON KY
40033-1150
US

V. Phone/Fax

Practice location:
  • Phone: 270-465-7896
  • Fax:
Mailing address:
  • Phone: 270-465-7896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberA001748
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: