Provider Demographics
NPI:1720230873
Name:WIEGAND, KIMBERLY SUE (CFM)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SUE
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:CFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 N CENTER ST
Mailing Address - Street 2:RTE 159
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5624
Mailing Address - Country:US
Mailing Address - Phone:618-288-7474
Mailing Address - Fax:618-288-7037
Practice Address - Street 1:2700 N CENTER ST
Practice Address - Street 2:RTE 159
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5624
Practice Address - Country:US
Practice Address - Phone:618-288-7474
Practice Address - Fax:618-288-7037
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049-177617183700000X
ILCFM01697225000000X
IL95212363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No183700000XPharmacy Service ProvidersPharmacy Technician
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical