Provider Demographics
NPI:1013806843
Name:WIEDEMAN, MICHELLE ROSE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ROSE
Last Name:WIEDEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N JUNIATA AVE LOT 20
Mailing Address - Street 2:
Mailing Address - City:JUNIATA
Mailing Address - State:NE
Mailing Address - Zip Code:68955
Mailing Address - Country:US
Mailing Address - Phone:402-751-4066
Mailing Address - Fax:
Practice Address - Street 1:110 N JUNIATA AVE LOT 20
Practice Address - Street 2:
Practice Address - City:JUNIATA
Practice Address - State:NE
Practice Address - Zip Code:68955-2223
Practice Address - Country:US
Practice Address - Phone:402-705-9510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-27
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor