Provider Demographics
NPI:1679376883
Name:WEIDA, NAOMI NICOLE (NP)
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:NICOLE
Last Name:WEIDA
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S PADRE CANYON DR
Mailing Address - Street 2:
Mailing Address - City:IVINS
Mailing Address - State:UT
Mailing Address - Zip Code:84738-6022
Mailing Address - Country:US
Mailing Address - Phone:435-236-5887
Mailing Address - Fax:
Practice Address - Street 1:120 S PADRE CANYON DRIVE
Practice Address - Street 2:
Practice Address - City:IVINS
Practice Address - State:UT
Practice Address - Zip Code:84738
Practice Address - Country:US
Practice Address - Phone:435-236-5887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12677395-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty