Provider Demographics
NPI:1346443413
Name:WEDVIK, AILEEN LESLIE (ARNP)
Entity Type:Individual
Prefix:
First Name:AILEEN
Middle Name:LESLIE
Last Name:WEDVIK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:AILEEN
Other - Middle Name:L
Other - Last Name:MABRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 98886
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98496-8886
Mailing Address - Country:US
Mailing Address - Phone:253-589-6484
Mailing Address - Fax:253-984-1079
Practice Address - Street 1:4909 108TH ST SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3724
Practice Address - Country:US
Practice Address - Phone:253-581-3075
Practice Address - Fax:253-581-3178
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005688363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9653155Medicaid
WAG8866736Medicare PIN
WA9653155Medicaid