Provider Demographics
NPI:1417368762
Name:WEAVER, JAQUELINE
Entity Type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:
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 1:93 SHEFFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14220-1916
Mailing Address - Country:US
Mailing Address - Phone:716-713-6442
Mailing Address - Fax:
Practice Address - Street 1:93 SHEFFIELD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14220-1916
Practice Address - Country:US
Practice Address - Phone:716-713-6442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305722164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse