Provider Demographics
NPI:1306397088
Name:WEAVER, METTA KATHERINE LEE (APRN, CNM)
Entity Type:Individual
Prefix:
First Name:METTA
Middle Name:KATHERINE LEE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:APRN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 E 41ST ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-6348
Mailing Address - Country:US
Mailing Address - Phone:208-742-4784
Mailing Address - Fax:
Practice Address - Street 1:412 E 41ST ST STE 2
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-6348
Practice Address - Country:US
Practice Address - Phone:208-742-4784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID54221163W00000X, 367A00000X
OR10009959163W00000X
NM852367A00000X
MO2023027340367A00000X
UT13419449-4402367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse