Provider Demographics
NPI:1255414579
Name:WIEDENHOEFT, MARY KATHRYN (OM LAC NCCDOM)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHRYN
Last Name:WIEDENHOEFT
Suffix:
Gender:F
Credentials:OM LAC NCCDOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12717 NW 11TH COURT
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323
Mailing Address - Country:US
Mailing Address - Phone:954-328-2964
Mailing Address - Fax:954-389-8404
Practice Address - Street 1:17130 ROYAL PALM BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326
Practice Address - Country:US
Practice Address - Phone:954-389-8404
Practice Address - Fax:954-389-8404
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP1975171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist