Provider Demographics
NPI:1871827352
Name:WEIDNER, JAMIE LYNN (NP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:WEIDNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9347 PENDLETON PIKE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-2768
Mailing Address - Country:US
Mailing Address - Phone:317-612-3196
Mailing Address - Fax:317-612-3270
Practice Address - Street 1:9347 PENDLETON PIKE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-2768
Practice Address - Country:US
Practice Address - Phone:317-612-3193
Practice Address - Fax:317-612-3270
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003106A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000638748OtherANTHEM BCBS
IN200960050Medicaid
IN176390OMedicare PIN
IN000000638748OtherANTHEM BCBS