Provider Demographics
NPI:1386815710
Name:WEAVER, STACY R
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:R
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 1:2210 HAMILTON DR
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50014-8287
Mailing Address - Country:US
Mailing Address - Phone:515-357-5078
Mailing Address - Fax:515-357-5032
Practice Address - Street 1:1275 SW STATE ST
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-2545
Practice Address - Country:US
Practice Address - Phone:515-357-5078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA82165225100000X
MN7552225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist