Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 124Q00000X | Dental Hygienist | DH-010901-L | PA |
Y | 124Q00000X | Dental Hygienist | PHDH000989 | PA |
NPI | 1043713944 |
---|---|
Provider Name | Susan Lea Wienand |
First Address | Philadelphia, PA 19128-2507 |
Second Address | Aston, PA 19014-1444 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/03/2018 |
Last Update Date | 16/03/2018 |