Provider Demographics
NPI:1144882069
Name:WEIDLER-EDHOLM, BRIANA R (NP)
Entity type:Individual
Prefix:
First Name:BRIANA
Middle Name:R
Last Name:WEIDLER-EDHOLM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17501 GENERATIONS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1589
Mailing Address - Country:US
Mailing Address - Phone:574-234-0049
Mailing Address - Fax:574-512-2871
Practice Address - Street 1:17501 GENERATIONS DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1589
Practice Address - Country:US
Practice Address - Phone:574-234-0049
Practice Address - Fax:574-251-2871
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28226873A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner