Provider Demographics
NPI:1164135521
Name:WIEBUSCH, KATHY MAE (RN)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:MAE
Last Name:WIEBUSCH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14216 SILVEROD ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3268
Mailing Address - Country:US
Mailing Address - Phone:763-772-5764
Mailing Address - Fax:
Practice Address - Street 1:500 W MAIN ST STE 11
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2000
Practice Address - Country:US
Practice Address - Phone:763-753-8658
Practice Address - Fax:763-753-4314
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-30
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1224649163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health