Provider Demographics
NPI:1225612435
Name:WIESNER, ROBIN KATE BEVIN (LAC)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:KATE BEVIN
Last Name:WIESNER
Suffix:
Gender:F
Credentials:LAC
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 1351
Mailing Address - Street 2:
Mailing Address - City:STEVENSON
Mailing Address - State:WA
Mailing Address - Zip Code:98648-1351
Mailing Address - Country:US
Mailing Address - Phone:631-258-6493
Mailing Address - Fax:
Practice Address - Street 1:640 NE MAJOR ST
Practice Address - Street 2:
Practice Address - City:STEVENSON
Practice Address - State:WA
Practice Address - Zip Code:98648-6347
Practice Address - Country:US
Practice Address - Phone:631-258-6493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC204758171100000X
AZLAC0100030171100000X
WAAC61019238171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist