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NPI Code Detail

MEDICARE: LILY WEIDALL RN

MEDICARE: LILY WEIDALL RN
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
1163W00000XRegistered Nurse1690163MN

General Provider Information

NPI Number : 1366384620
Entity Type Code : Individual
Provider Name (Legal Business Name) : LILY WEIDALL RN
Provider Business Mailing Address
First Line : 18190 OLINDA TRL N
Second Line :
City : MARINE ON SAINT CROIX
State : MN
Zip : 55047-8636
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1500 CURVE CREST BLVD W
Second Line :
City : STILLWATER
State : MN
Zip : 55082-6040
Country : US
Telephone Number : 651-439-1234
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/07/2026
Last Update Date : 04/07/2026

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