Provider Demographics
NPI:1689422305
Name:WEATHERLY, RACHEL LEE (RDH, BSDH, QOM)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:LEE
Last Name:WEATHERLY
Suffix:
Gender:F
Credentials:RDH, BSDH, QOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 1ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-2507
Mailing Address - Country:US
Mailing Address - Phone:507-440-8490
Mailing Address - Fax:
Practice Address - Street 1:800 1ST AVE SW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-2507
Practice Address - Country:US
Practice Address - Phone:507-440-8490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH11087124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist