Basic Information
| Provider Information | |||||||||
| NPI: | 1720756992 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIEST | ||||||||
| FirstName: | RAELYNNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2344 6TH ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947102412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109814100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 837 ADDISON ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108096331 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2021 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95018071 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.