Provider Demographics
NPI:1619332715
Name:WEIGAND, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WEIGAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5629 COLLEEN LN
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5629 COLLEEN LN
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9729
Practice Address - Country:US
Practice Address - Phone:262-334-2984
Practice Address - Fax:262-334-2984
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI221015-30163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics