Provider Demographics
NPI:1144788894
Name:WEIDNER, ALICE (OM)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:WEIDNER
Suffix:
Gender:F
Credentials:OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:BARTO
Mailing Address - State:PA
Mailing Address - Zip Code:19504-9054
Mailing Address - Country:US
Mailing Address - Phone:215-679-4554
Mailing Address - Fax:215-679-0500
Practice Address - Street 1:120 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:BARTO
Practice Address - State:PA
Practice Address - Zip Code:19504-9054
Practice Address - Country:US
Practice Address - Phone:215-679-4554
Practice Address - Fax:215-679-0500
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOM000113171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOM000113OtherORIENTAL MEDICINE LICENSE