Provider Demographics
NPI:1639359847
Name:WEIDEMAN, KATHLEEN E (FNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
Last Name:WEIDEMAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 COMMONS ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4651
Mailing Address - Country:US
Mailing Address - Phone:802-747-3359
Mailing Address - Fax:802-786-5204
Practice Address - Street 1:10 COMMONS ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4651
Practice Address - Country:US
Practice Address - Phone:802-747-3359
Practice Address - Fax:802-786-5204
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0038406363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT459902Medicare PIN