Provider Demographics
NPI:1235657552
Name:WEAVER, KELLY ANNE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2453 BEE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-6304
Mailing Address - Country:US
Mailing Address - Phone:941-955-8076
Mailing Address - Fax:941-955-0453
Practice Address - Street 1:1012 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-8811
Practice Address - Country:US
Practice Address - Phone:863-494-2663
Practice Address - Fax:863-494-2649
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9263549363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health