Provider Demographics
NPI:1437309838
Name:WEAVER, KRISTINE MARIE (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:MARIE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CEDAR ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8707
Mailing Address - Fax:
Practice Address - Street 1:232 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:CULVER
Practice Address - State:IN
Practice Address - Zip Code:46511
Practice Address - Country:US
Practice Address - Phone:574-335-7780
Practice Address - Fax:574-335-0730
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002758A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN187720061OtherMEDICARE
IN000000878284OtherBCBS
INP01942591OtherRR MEDICARE
IN000001170309OtherBCBS (ELM RD)
IN200936570Medicaid