Healthcare Provider Details

I. General information

NPI: 1629571443
Provider Name (Legal Business Name): KAYLA MARIE WEIGEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2018
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 BROADWAY N
FARGO ND
58102-1406
US

IV. Provider business mailing address

4785 44TH ST S
FARGO ND
58104-4284
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2900
  • Fax:
Mailing address:
  • Phone: 701-866-2946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberR36567
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR36567
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: