Provider Demographics
NPI:1154681500
Name:WIESE, SARA NICOLE (RNC)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:NICOLE
Last Name:WIESE
Suffix:
Gender:F
Credentials:RNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 WYSS ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534-7493
Mailing Address - Country:US
Mailing Address - Phone:970-396-4039
Mailing Address - Fax:
Practice Address - Street 1:249 WYSS ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534-7493
Practice Address - Country:US
Practice Address - Phone:970-396-4039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-19
Last Update Date:2012-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO177265163WM0102X, 163WN0002X, 163WN0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No163WN0003XNursing Service ProvidersRegistered NurseNeonatal, Low-Risk