Provider Demographics
NPI:1366605164
Name:WEISE, REGINA
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:
Last Name:WEISE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:REGINA
Other - Middle Name:
Other - Last Name:WEISE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:5813 UNICORN DR APT 4
Mailing Address - Street 2:
Mailing Address - City:SANBORN
Mailing Address - State:NY
Mailing Address - Zip Code:14132-9260
Mailing Address - Country:US
Mailing Address - Phone:716-578-7678
Mailing Address - Fax:
Practice Address - Street 1:5813 UNICORN DR APT 4
Practice Address - Street 2:
Practice Address - City:SANBORN
Practice Address - State:NY
Practice Address - Zip Code:14132-9260
Practice Address - Country:US
Practice Address - Phone:716-578-7678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153892164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse