Provider Demographics
NPI:1598734097
Name:WIETSMA, ANN DEPAOLO (AUD)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:DEPAOLO
Last Name:WIETSMA
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:MS
Other - First Name:ANN
Other - Middle Name:
Other - Last Name:DEPAOLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AUD
Mailing Address - Street 1:PO BOX 1911
Mailing Address - Street 2:45 N MAIN STREET
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-1911
Mailing Address - Country:US
Mailing Address - Phone:804-435-0758
Mailing Address - Fax:804-435-7226
Practice Address - Street 1:45 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KILMARNOCK
Practice Address - State:VA
Practice Address - Zip Code:22482-8501
Practice Address - Country:US
Practice Address - Phone:804-435-0758
Practice Address - Fax:804-435-7226
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201001146231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist