Provider Demographics
NPI:1104133933
Name:WIECHMANN, CARRIE ANN (NP)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANN
Last Name:WIECHMANN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:ANN
Other - Last Name:MOAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4350 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-1017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4350 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105
Practice Address - Country:US
Practice Address - Phone:310-423-2641
Practice Address - Fax:310-423-2356
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE114003363L00000X
CA19188363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03494828Medicaid
NYJ400121598Medicare PIN
NYJ400121653Medicare PIN
NYJ400117769Medicare PIN