Provider Demographics
NPI:1568800894
Name:WIESE, CHRISTINE MARIE (ANP-BC)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:MARIE
Last Name:WIESE
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2969
Mailing Address - Country:US
Mailing Address - Phone:763-581-2800
Mailing Address - Fax:763-581-2801
Practice Address - Street 1:3435 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2969
Practice Address - Country:US
Practice Address - Phone:763-581-2800
Practice Address - Fax:763-581-2801
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-09
Last Update Date:2013-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 180600-9363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner