Provider Demographics
NPI:1609260116
Name:WIESEHAN, HOLLY JOY (ACNP)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:JOY
Last Name:WIESEHAN
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-1291
Mailing Address - Fax:314-747-8213
Practice Address - Street 1:1020 N MASON RD STE 100
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6300
Practice Address - Country:US
Practice Address - Phone:314-362-1291
Practice Address - Fax:314-747-8213
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015006317363LA2100X, 363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420021322Medicaid