Provider Demographics
NPI:1154607513
Name:WEIDMAN WILSON, KYNA (DC)
Entity type:Individual
Prefix:DR
First Name:KYNA
Middle Name:
Last Name:WEIDMAN WILSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-3705
Mailing Address - Country:US
Mailing Address - Phone:360-249-2700
Mailing Address - Fax:
Practice Address - Street 1:209 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-3705
Practice Address - Country:US
Practice Address - Phone:360-249-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603135337111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor