Provider Demographics
NPI:1437786472
Name:WEATHERLY, LYNDSEY
Entity Type:Individual
Prefix:
First Name:LYNDSEY
Middle Name:
Last Name:WEATHERLY
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 1:114 UNDERCLIFF TER
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2174
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MERCER MEDICAL GROUP PEDIATRICS
Practice Address - Street 2:114 UNDERCLIFF TERRACE
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2174
Practice Address - Country:US
Practice Address - Phone:304-425-0025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV32808208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program