Provider Demographics
NPI:1548230196
Name:WIENER, PHYLLIS C (WHCNP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:C
Last Name:WIENER
Suffix:
Gender:F
Credentials:WHCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4028 ELLIOT AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3147
Mailing Address - Country:US
Mailing Address - Phone:612-822-1548
Mailing Address - Fax:
Practice Address - Street 1:1200 LAGOON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2077
Practice Address - Country:US
Practice Address - Phone:612-823-6300
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1017050363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1075705OtherAMERICA'S PPO (ARAZ)
07-14658OtherMEDICA
MN5K166WIOtherBCBS MN
1017710OtherPREFERRED ONE
142730OtherUCARE
28721OtherSIOUX VALLEY HEALTH PLAN
HP17896OtherHEALTH PARTNERS
142730OtherUCARE