Provider Demographics
NPI:1144348954
Name:WIESEHAN, PAULA LYNNE (FNP)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:LYNNE
Last Name:WIESEHAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:PAULA
Other - Middle Name:
Other - Last Name:WIESEHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:5455 ALMIRA DR NE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-8330
Mailing Address - Country:US
Mailing Address - Phone:360-373-5031
Mailing Address - Fax:
Practice Address - Street 1:5455 ALMIRA DR NE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-8330
Practice Address - Country:US
Practice Address - Phone:360-373-5031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO123435363LF0000X
MO2013042951363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO424914703Medicaid
MO424914703Medicaid
Q77441Medicare UPIN