Provider Demographics
NPI:1275584534
Name:WELLER, KATIE L (CFNP)
Entity Type:Individual
Prefix:MS
First Name:KATIE
Middle Name:L
Last Name:WELLER
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:MISS
Other - First Name:KATIE
Other - Middle Name:L
Other - Last Name:VARIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-5124
Mailing Address - Country:US
Mailing Address - Phone:541-426-7900
Mailing Address - Fax:541-426-7901
Practice Address - Street 1:603 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-5124
Practice Address - Country:US
Practice Address - Phone:541-426-7900
Practice Address - Fax:541-426-7901
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP741A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807425100Medicaid
ID807425100Medicaid
P00427855Medicare PIN
1345483Medicare PIN