Provider Demographics
NPI:1093434516
Name:WEIGT, KANADA NICOLE CHERI (DPT)
Entity Type:Individual
Prefix:
First Name:KANADA
Middle Name:NICOLE CHERI
Last Name:WEIGT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 168
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-0168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:385 SPEARS CREEK CHURCH RD STE B
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-8446
Practice Address - Country:US
Practice Address - Phone:803-929-4708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11543225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist