Individual
MRS. TAMMY LYNN WIETIES
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OD
Contact information
Practice address
905 W MEFFORD ST, ROBINSON, IL 62454-1065
(618) 544-3525
(618) 544-3261
Mailing address
905 W MEFFORD ST, ROBINSON, IL 62454-1065
(618) 544-3525
(618) 544-3261
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
046008222
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01732006
BLUE CROSS BLUE SHIELD
IL
01
—
281651
HEALTHLINK
IL
Enumeration date
08/09/2005
Last updated
02/22/2012
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