Provider Demographics
NPI:1477807444
Name:WEAVER, DANELLE (ADULT NP-BC,PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DANELLE
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:ADULT NP-BC,PMHNP-BC
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5633 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-6901
Mailing Address - Country:US
Mailing Address - Phone:850-896-5018
Mailing Address - Fax:
Practice Address - Street 1:4624 PARK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-7327
Practice Address - Country:US
Practice Address - Phone:904-503-0131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9227262363LA2200X
FL9227262363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102378500Medicaid