Provider Demographics
NPI:1609492180
Name:WEICKUM, DEJANAE SHAQUELLE (LPN)
Entity Type:Individual
Prefix:
First Name:DEJANAE
Middle Name:SHAQUELLE
Last Name:WEICKUM
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 1:14124 MERIDIAN E APT I107
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-6101
Mailing Address - Country:US
Mailing Address - Phone:253-239-7998
Mailing Address - Fax:
Practice Address - Street 1:721 FAWCETT AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5502
Practice Address - Country:US
Practice Address - Phone:253-597-6728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-22
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP61053332164W00000X
WARN61353026163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse