1548289259 NPI number — JUDITH HILARY WEIS MA, RN, CNS

Table of content: JUDITH HILARY WEIS MA, RN, CNS (NPI 1548289259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548289259 NPI number — JUDITH HILARY WEIS MA, RN, CNS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEIS
Provider First Name:
JUDITH
Provider Middle Name:
HILARY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, RN, CNS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAVIS
Provider Other First Name:
JUDITH
Provider Other Middle Name:
HILARY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548289259
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 102
Provider Second Line Business Mailing Address:
27 SW FIRST STREET
Provider Business Mailing Address City Name:
CROSBY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56441-0102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-545-1154
Provider Business Mailing Address Fax Number:
218-545-1155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27 1ST ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROSBY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56441-1417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-545-1154
Provider Business Practice Location Address Fax Number:
218-545-1155
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 364SP0808X , with the licence number:  RO741961 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 531227200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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