Healthcare Provider Details

I. General information

NPI: 1730072554
Provider Name (Legal Business Name): KATIE WEIDEMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2025
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1684 HINES BLVD
BURNS OR
97720-2345
US

IV. Provider business mailing address

1684 HINES BLVD
BURNS OR
97720-2345
US

V. Phone/Fax

Practice location:
  • Phone: 541-589-3146
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number10011319
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: