Provider Demographics
NPI: | 1134124902 |
---|---|
Name: | WEAVER, LISA ANN (FNP-C) |
Entity Type: | Individual |
Prefix: | MS |
First Name: | LISA |
Middle Name: | ANN |
Last Name: | WEAVER |
Suffix: | |
Gender: | F |
Credentials: | FNP-C |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 104 IVY LN |
Mailing Address - Street 2: | |
Mailing Address - City: | PULASKI |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 38478-4550 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 931-424-1330 |
Mailing Address - Fax: | 931-424-0019 |
Practice Address - Street 1: | 104 IVY LN |
Practice Address - Street 2: | |
Practice Address - City: | PULASKI |
Practice Address - State: | TN |
Practice Address - Zip Code: | 38478-4550 |
Practice Address - Country: | US |
Practice Address - Phone: | 931-424-1330 |
Practice Address - Fax: | 931-424-0019 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2005-06-16 |
Last Update Date: | 2009-10-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TN | 79070 | 363LF0000X |
TN | 6319 | 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TN | 3344019 | Medicaid | |
TN | 3710887 | Other | MEDICARE GROUP NUMBER |
1659447654 | Other | NPI GROUP NUMBER | |
TN | P00158812 | Medicare PIN | |
1659447654 | Other | NPI GROUP NUMBER |