Healthcare Provider Details

I. General information

NPI: 1619332715
Provider Name (Legal Business Name): MARY WEIGAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2015
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5629 COLLEEN LN
WEST BEND WI
53095-9729
US

IV. Provider business mailing address

5629 COLLEEN LN
WEST BEND WI
53095-9729
US

V. Phone/Fax

Practice location:
  • Phone: 262-334-2984
  • Fax: 262-334-2984
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number221015-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: