Healthcare Provider Details

I. General information

NPI: 1447836929
Provider Name (Legal Business Name): JENNIFER RENEE WIEDERHOLD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4049 MAIN ST
CHINCOTEAGUE ISLAND VA
23336-2406
US

IV. Provider business mailing address

20280 MARKET ST
ONANCOCK VA
23417-1331
US

V. Phone/Fax

Practice location:
  • Phone: 757-336-3682
  • Fax: 757-336-3703
Mailing address:
  • Phone: 757-414-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024198588
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: