MEDICARE: JUDY CLAYTON-WIESE 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
1	163W00000X	Registered Nurse	123887	MO

General Provider Information

NPI Number	:	1891238721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDY CLAYTON-WIESE RN

Provider Business Mailing Address
First Line	:	5649 SOUTHWEST AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-1650
Country	:	US
Telephone Number	:	314-250-2812
Fax Number	:

Provider Business Practice Location Address
First Line	:	5649 SOUTHWEST AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-1650
Country	:	US
Telephone Number	:	314-250-2812
Fax Number	:

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

Provider Enumeration Date	:	11/26/2016
Last Update Date	:	11/26/2016

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