Healthcare Provider Details

I. General information

NPI: 1679088397
Provider Name (Legal Business Name): JEANNA WIZNER HID
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 PAUL BUNYAN DR NW STE 106
BEMIDJI MN
56601-2132
US

IV. Provider business mailing address

1710 PAUL BUNYAN DR NW STE 106
BEMIDJI MN
56601-2132
US

V. Phone/Fax

Practice location:
  • Phone: 218-444-0875
  • Fax: 218-444-0876
Mailing address:
  • Phone: 218-444-0875
  • Fax: 218-444-0876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2810
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: