Provider Demographics
NPI:1356462766
Name:WIEDEMANN, CHRISTINE L
Entity type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:L
Last Name:WIEDEMANN
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 1:12 MARTIN STREET
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:14895-1057
Mailing Address - Country:US
Mailing Address - Phone:585-593-6041
Mailing Address - Fax:
Practice Address - Street 1:12 MARTIN STREET
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:UT
Practice Address - Zip Code:14895-1057
Practice Address - Country:US
Practice Address - Phone:585-593-6041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007696156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician