Healthcare Provider Details

I. General information

NPI: 1538980313
Provider Name (Legal Business Name): KENAN WEIDNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 AUTUMN HARVEST LANE
LITITZ PA
17543
US

IV. Provider business mailing address

313 AUTUMN HARVEST LANE
LITITZ PA
17543
US

V. Phone/Fax

Practice location:
  • Phone: 610-780-1523
  • Fax:
Mailing address:
  • Phone: 610-780-1523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP030911
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: