Basic Information
| Provider Information | |||||||||
| NPI: | 1861861841 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEIDNER | ||||||||
| FirstName: | TESS | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 E GOLDSTONE WAY | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083021200 | ||||||||
| FaxNumber: | 2083021255 | ||||||||
| Practice Location | |||||||||
| Address1: | 1072 N LIBERTY STREET | ||||||||
| Address2: | STE 100 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083021200 | ||||||||
| FaxNumber: | 2083021255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2015 | ||||||||
| LastUpdateDate: | 11/09/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | 001708 | NY | N | Other Service Providers | Midwife | 367A00000X | 56605 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.