Provider Demographics
NPI:1275313041
Name:WIEBECK SWEETLAND, BONNIE ANN (LAC)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:ANN
Last Name:WIEBECK SWEETLAND
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1353 SW MCGINNIS AVE
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-1566
Mailing Address - Country:US
Mailing Address - Phone:608-630-5702
Mailing Address - Fax:
Practice Address - Street 1:16821 SE MCGILLIVRAY BLVD STE 110
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-0401
Practice Address - Country:US
Practice Address - Phone:360-718-8544
Practice Address - Fax:360-718-5243
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC61471618171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist