Provider Demographics
NPI:1851563027
Name:WIEGAND, CHANTE (ND)
Entity Type:Individual
Prefix:
First Name:CHANTE
Middle Name:
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3913
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-3913
Mailing Address - Country:US
Mailing Address - Phone:208-201-7064
Mailing Address - Fax:
Practice Address - Street 1:525 E KELLY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8546
Practice Address - Country:US
Practice Address - Phone:208-201-7064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT00001633175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath