Healthcare Provider Details

I. General information

NPI: 1083375166
Provider Name (Legal Business Name): KALI BRIANNE WIELAND FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25723 OLD FREDERICKSBURG RD
BOERNE TX
78015-6605
US

IV. Provider business mailing address

25723 OLD FREDERICKSBURG RD
BOERNE TX
78015-6605
US

V. Phone/Fax

Practice location:
  • Phone: 210-450-6810
  • Fax: 210-450-6023
Mailing address:
  • Phone: 210-450-6810
  • Fax: 210-450-6023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1056581
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: