Provider Demographics
NPI:1225499064
Name:WIEMAR, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WIEMAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12002 SAILING AWAY ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78233-4228
Mailing Address - Country:US
Mailing Address - Phone:901-412-4883
Mailing Address - Fax:
Practice Address - Street 1:12412 JUDSON RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3255
Practice Address - Country:US
Practice Address - Phone:210-757-5021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-153368163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse