Provider Demographics
NPI:1861861841
Name:WEIDNER, TESS (CNM)
Entity Type:Individual
Prefix:
First Name:TESS
Middle Name:
Last Name:WEIDNER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-1200
Mailing Address - Fax:208-302-1255
Practice Address - Street 1:1072 N LIBERTY STREET
Practice Address - Street 2:STE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-302-1200
Practice Address - Fax:208-302-1255
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-19
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001708176B00000X
ID56605367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife