Provider Demographics
NPI:1952911083
Name:WIEDEMAN, HALEY RAEANNE
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:RAEANNE
Last Name:WIEDEMAN
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 1:2214 MESA AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-6670
Mailing Address - Country:US
Mailing Address - Phone:970-312-6511
Mailing Address - Fax:
Practice Address - Street 1:1100 NORTH AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-3122
Practice Address - Country:US
Practice Address - Phone:970-312-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer