Provider Demographics
NPI:1134118748
Name:WEISENBURGER, KELLIE (FNP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:WEISENBURGER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 253
Mailing Address - Street 2:
Mailing Address - City:UNDERWOOD
Mailing Address - State:ND
Mailing Address - Zip Code:58576-0253
Mailing Address - Country:US
Mailing Address - Phone:701-442-3148
Mailing Address - Fax:701-442-3414
Practice Address - Street 1:87 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:UNDERWOOD
Practice Address - State:ND
Practice Address - Zip Code:58576
Practice Address - Country:US
Practice Address - Phone:701-442-3148
Practice Address - Fax:701-442-3414
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR25051363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND025563OtherBCBS
ND19789Medicaid
A63211044293OtherPREFERRED ONE
007OtherAMERICA'S PPO
ND025564OtherBCBS
P00300571OtherRR MEDICARE
ND025563OtherBCBS
P00300571OtherRR MEDICARE