Provider Demographics
NPI:1174281885
Name:WEAVER, ANN MARIE (RD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 N POWER RD APT 3030
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-2983
Mailing Address - Country:US
Mailing Address - Phone:417-379-3355
Mailing Address - Fax:
Practice Address - Street 1:2217 N POWER RD APT 3030
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-2983
Practice Address - Country:US
Practice Address - Phone:417-379-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1035016133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1035016OtherCOMMISSION ON DIETETIC REGISTRATION