Provider Demographics
NPI:1235204744
Name:WIETFELDT, DAWN (DC)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:WIETFELDT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 STONECREST COURT
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065
Mailing Address - Country:US
Mailing Address - Phone:502-647-4600
Mailing Address - Fax:502-647-4607
Practice Address - Street 1:4123 TAYLOR BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-2341
Practice Address - Country:US
Practice Address - Phone:502-363-7172
Practice Address - Fax:502-363-7174
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4867111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7045635OtherAETNA
KY000000349858OtherANTHEM
KY000000349858OtherANTHEM