Provider Demographics
NPI:1356646087
Name:WEAVER, ROBERTA CHRISTINE (FNP)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:CHRISTINE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:CHRISTINE
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1313 BROADWAY STE 5
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79401-3209
Mailing Address - Country:US
Mailing Address - Phone:806-765-2611
Mailing Address - Fax:806-687-5957
Practice Address - Street 1:1318 BROADWAY
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79401-3206
Practice Address - Country:US
Practice Address - Phone:806-765-2611
Practice Address - Fax:806-765-6271
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX648686364SF0001X
TXAP119780363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health