Provider Demographics
NPI:1720637556
Name:WIESEN, DIEM
Entity Type:Individual
Prefix:
First Name:DIEM
Middle Name:
Last Name:WIESEN
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 1:1619 BROAD WINGED HAWK DR
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-4955
Mailing Address - Country:US
Mailing Address - Phone:440-590-3071
Mailing Address - Fax:
Practice Address - Street 1:1619 BROAD WINGED HAWK DR
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33570-4955
Practice Address - Country:US
Practice Address - Phone:440-590-3071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9508713163W00000X
FL11003120363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse