Provider Demographics
NPI:1336792183
Name:WEIDENBENNER, DANA (LAC, MSTOM)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:WEIDENBENNER
Suffix:
Gender:F
Credentials:LAC, MSTOM
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 24
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47547-0024
Mailing Address - Country:US
Mailing Address - Phone:812-639-1961
Mailing Address - Fax:
Practice Address - Street 1:725 W 6TH ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-2629
Practice Address - Country:US
Practice Address - Phone:812-639-1961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist