Provider Demographics
NPI:1174158695
Name:WIESNER, ANNETTE MARIE (FNP)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MARIE
Last Name:WIESNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 BUNN HILL RD
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-5913
Mailing Address - Country:US
Mailing Address - Phone:607-624-0351
Mailing Address - Fax:
Practice Address - Street 1:225 VESTAL PKWY E
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1629
Practice Address - Country:US
Practice Address - Phone:607-752-2692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331330363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily