Provider Demographics
NPI:1104183391
Name:WIESNER, REBECCA (DPM)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:WIESNER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1379 ENFIELD ST
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-5524
Mailing Address - Country:US
Mailing Address - Phone:860-741-3041
Mailing Address - Fax:860-741-5644
Practice Address - Street 1:1379 ENFIELD ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-5524
Practice Address - Country:US
Practice Address - Phone:860-741-3041
Practice Address - Fax:860-741-5644
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2228213ES0103X
390200000X
CT926213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program