Provider Demographics
NPI:1548289259
Name:WEIS, JUDITH HILARY (MA, RN, CNS)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:HILARY
Last Name:WEIS
Suffix:
Gender:F
Credentials:MA, RN, CNS
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:HILARY
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:27 SW FIRST STREET
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-0102
Mailing Address - Country:US
Mailing Address - Phone:218-545-1154
Mailing Address - Fax:218-545-1155
Practice Address - Street 1:27 1ST ST SW
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1417
Practice Address - Country:US
Practice Address - Phone:218-545-1154
Practice Address - Fax:218-545-1155
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNRO741961364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN531227200Medicaid
MN531227200Medicaid