Provider Demographics
NPI:1013071836
Name:WEISS, WENDY E (LIC AC)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:E
Last Name:WEISS
Suffix:
Gender:F
Credentials:LIC AC
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 105
Mailing Address - Street 2:
Mailing Address - City:LOWER LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95457-0105
Mailing Address - Country:US
Mailing Address - Phone:707-277-0891
Mailing Address - Fax:707-277-0891
Practice Address - Street 1:9667 HWY 29
Practice Address - Street 2:SUITE 202
Practice Address - City:LOWER LAKE
Practice Address - State:CA
Practice Address - Zip Code:95457-4804
Practice Address - Country:US
Practice Address - Phone:707-277-0891
Practice Address - Fax:707-277-0891
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4208171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist