Provider Demographics
NPI:1003943945
Name:WEIMAN, KATHLEEN B (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:B
Last Name:WEIMAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 RIDGE LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9411
Mailing Address - Country:US
Mailing Address - Phone:901-685-6150
Mailing Address - Fax:901-685-6454
Practice Address - Street 1:825 RIDGE LAKE BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-9411
Practice Address - Country:US
Practice Address - Phone:901-685-6150
Practice Address - Fax:901-685-6454
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000094606367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN430065684OtherRAILROAD MEDICARE
TN4072551OtherBLUECROSS BLUESHIELD
TN621839766OtherRIDGELAKE TAX ID#
TN3622391Medicaid
TN3622396Medicare ID - Type Unspecified