MEDICARE: MARILYN A WIEDEMANN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WA2000X	Administrator Registered Nurse	244179	CA

General Provider Information

NPI Number	:	1164048682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILYN A WIEDEMANN

Provider Business Mailing Address
First Line	:	12089 MERIDEN LN
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-4339
Country	:	US
Telephone Number	:	858-405-8502
Fax Number	:

Provider Business Practice Location Address
First Line	:	12089 MERIDEN LN
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-4339
Country	:	US
Telephone Number	:	858-405-8502
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2020
Last Update Date	:	11/27/2023

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