Provider Demographics
NPI:1609023084
Name:WIEGAND, LEAH ROSE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:ROSE
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 S. OXFORD AVE
Mailing Address - Street 2:APT 142
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235
Mailing Address - Country:US
Mailing Address - Phone:920-210-9464
Mailing Address - Fax:
Practice Address - Street 1:925 S. OXFORD AVE
Practice Address - Street 2:APT 142
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235
Practice Address - Country:US
Practice Address - Phone:920-210-9464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI306128-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse