Provider Demographics
NPI:1326929795
Name:WIEDRICH, SALLY LYNN
Entity type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:LYNN
Last Name:WIEDRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 SILVER FOX LN
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-6809
Mailing Address - Country:US
Mailing Address - Phone:701-880-8856
Mailing Address - Fax:
Practice Address - Street 1:3330 SILVER FOX LN
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-6809
Practice Address - Country:US
Practice Address - Phone:701-880-8856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty