Provider Demographics
NPI:1669083952
Name:WIEGANDT, ANNA
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:WIEGANDT
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 1:108 E POPLAR DR APT A
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-2218
Mailing Address - Country:US
Mailing Address - Phone:585-694-9187
Mailing Address - Fax:
Practice Address - Street 1:40 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:LENOX
Practice Address - State:MA
Practice Address - Zip Code:01240-2018
Practice Address - Country:US
Practice Address - Phone:413-637-5011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9786225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant