Provider Demographics
NPI:1871627851
Name:WIESLEY, ILYEEN KATHRYN (RPH)
Entity type:Individual
Prefix:
First Name:ILYEEN
Middle Name:KATHRYN
Last Name:WIESLEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 WALNUT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-9619
Mailing Address - Country:US
Mailing Address - Phone:515-224-0227
Mailing Address - Fax:
Practice Address - Street 1:805 WALNUT RIDGE DR
Practice Address - Street 2:
Practice Address - City:WAUKEE
Practice Address - State:IA
Practice Address - Zip Code:50263-9619
Practice Address - Country:US
Practice Address - Phone:515-224-0227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15737183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist