Provider Demographics
NPI:1861728495
Name:WIEDEMANN, JEANNE RAY (NNP-BC)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:RAY
Last Name:WIEDEMANN
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7720 N 16TH ST
Mailing Address - Street 2:STE 425
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4492
Mailing Address - Country:US
Mailing Address - Phone:602-476-8962
Mailing Address - Fax:623-643-9236
Practice Address - Street 1:7720 N 16TH ST
Practice Address - Street 2:STE 425
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4492
Practice Address - Country:US
Practice Address - Phone:602-476-8962
Practice Address - Fax:623-643-9236
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2464363LN0000X
AZRN080027163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ575555Medicaid