Provider Demographics
NPI:1730889403
Name:WEITLICH, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:WEITLICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 N OUTAGAMIE ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-3435
Mailing Address - Country:US
Mailing Address - Phone:920-470-3424
Mailing Address - Fax:
Practice Address - Street 1:417 N OUTAGAMIE ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3435
Practice Address - Country:US
Practice Address - Phone:920-470-3424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI226933-30163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine