Provider Demographics
NPI:1164831848
Name:WEASENFORTH, ANNA GRACE (AUD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:GRACE
Last Name:WEASENFORTH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 RILEY HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5109
Mailing Address - Country:US
Mailing Address - Phone:317-944-8868
Mailing Address - Fax:
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002589A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC188JSOtherBCBS
NCQ47704AOtherMEDICARE
SCSAN121Medicaid