Provider Demographics
NPI:1407421274
Name:WEAVER, MARY (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20498 W WALTON DR
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-3526
Mailing Address - Country:US
Mailing Address - Phone:910-386-6634
Mailing Address - Fax:
Practice Address - Street 1:20498 W WALTON DR
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85396-3526
Practice Address - Country:US
Practice Address - Phone:910-386-6634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ232648163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty