Provider Demographics
NPI:1356231013
Name:WEAVER, AMANDA L (RN, NP STUDENT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:WEAVER
Suffix:
Gender:F
Credentials:RN, NP STUDENT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:REAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4003B HIGHWAY 93
Mailing Address - Street 2:
Mailing Address - City:FILER
Mailing Address - State:ID
Mailing Address - Zip Code:83328-5586
Mailing Address - Country:US
Mailing Address - Phone:208-293-4530
Mailing Address - Fax:
Practice Address - Street 1:725 POLE LINE RD W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5800
Practice Address - Country:US
Practice Address - Phone:208-293-4530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-05
Last Update Date:2025-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID49195163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse