Provider Demographics
NPI:1235573551
Name:WIEDEMANN, SALLY BETHEA (RN)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:BETHEA
Last Name:WIEDEMANN
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 1:660 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-1126
Mailing Address - Country:US
Mailing Address - Phone:864-941-3447
Mailing Address - Fax:
Practice Address - Street 1:660 CENTER ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-1126
Practice Address - Country:US
Practice Address - Phone:864-941-3447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25939163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool