=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235351321
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICKIE ANNE WEIDNER PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 MEETING HOUSE LN
-----------------------------------------------------
City | SOUTHAMPTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11968-5009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-726-8520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 17TH AVE
-----------------------------------------------------
City | RONKONKOMA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11779-6248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-678-8249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 026419
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------