Provider Demographics
NPI:1174789010
Name:WIEGEL, DEADRA JEANNA (PTA)
Entity type:Individual
Prefix:MRS
First Name:DEADRA
Middle Name:JEANNA
Last Name:WIEGEL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:DEDE
Other - Middle Name:
Other - Last Name:WIEGEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:337 S HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1150
Mailing Address - Country:US
Mailing Address - Phone:270-465-7896
Mailing Address - Fax:
Practice Address - Street 1:337 S HARRISON ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1150
Practice Address - Country:US
Practice Address - Phone:270-465-7896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA001748172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker