Basic Information
| Provider Information | |||||||||
| NPI: | 1346634268 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEIDNER | ||||||||
| FirstName: | SERENA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 SPRINGER DR | ||||||||
| Address2: | |||||||||
| City: | LOMBARD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601486413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157448554 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10512 PARK RD STE 113 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282108469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045428018 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2015 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5008148 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 19321 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.