Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225000000X | Orthotic Fitter | CFM01697 | IL |
NPI | 1720230873 |
---|---|
Provider Name | Mrs. Kimberly Sue Wiegand |
First Address | Maryville, IL 62062-5624 |
Second Address | Maryville, IL 62062-5624 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/10/2008 |
Last Update Date | 21/10/2008 |