Healthcare Provider Details

I. General information

NPI: 1235204744
Provider Name (Legal Business Name): DAWN WIETFELDT DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4123 TAYLOR BLVD
LOUISVILLE KY
40215-2341
US

IV. Provider business mailing address

60 STONECREST COURT SUITE 140
SHELBYVILLE KY
40065
US

V. Phone/Fax

Practice location:
  • Phone: 502-363-7172
  • Fax: 502-363-7174
Mailing address:
  • Phone: 502-647-4600
  • Fax: 502-647-4607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4867
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: