Provider Demographics
NPI:1770674160
Name:WIEDEMANN, ALLISON LYNN (OD)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:LYNN
Last Name:WIEDEMANN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 NORTHTOWN DR NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-1043
Mailing Address - Country:US
Mailing Address - Phone:763-784-4081
Mailing Address - Fax:866-822-2088
Practice Address - Street 1:570 NORTHTOWN DR NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-1043
Practice Address - Country:US
Practice Address - Phone:763-784-4081
Practice Address - Fax:866-822-2088
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002322152W00000X
MN3164152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOPT002322OtherSTATE LICENSE
MN3164OtherMN OPTOMETRY LICENSE