Provider Demographics
NPI:1023074226
Name:WIEBER, MARY LYNN
Entity type:Individual
Prefix:
First Name:MARY LYNN
Middle Name:
Last Name:WIEBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CORAL REEF CT S
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8327
Mailing Address - Country:US
Mailing Address - Phone:386-237-0668
Mailing Address - Fax:
Practice Address - Street 1:102 FLAGLER PLAZA DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-5967
Practice Address - Country:US
Practice Address - Phone:386-439-0239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2009-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2077171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist