Healthcare Provider Details

I. General information

NPI: 1417931296
Provider Name (Legal Business Name): JULIE A. WIESE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 S MAIN ST
LAYTON UT
84041-7135
US

IV. Provider business mailing address

934 S MAIN ST
LAYTON UT
84041-7135
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-7060
  • Fax:
Mailing address:
  • Phone: 801-773-7060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number3090271205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: