Provider Demographics
NPI:1215066816
Name:WEITKUM, TERESA L (RN)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:WEITKUM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3149
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93423-3149
Mailing Address - Country:US
Mailing Address - Phone:805-466-4435
Mailing Address - Fax:805-466-4435
Practice Address - Street 1:2455 ARDILLA RD
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-1861
Practice Address - Country:US
Practice Address - Phone:805-466-4435
Practice Address - Fax:805-466-4435
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 500823171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN004470Medicaid
CAEPS016310Medicaid