Provider Demographics
NPI:1598730632
Name:WEISS, MARYLOU M (NP)
Entity Type:Individual
Prefix:MS
First Name:MARYLOU
Middle Name:M
Last Name:WEISS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 KEMPSVILLE RD
Mailing Address - Street 2:1ST FL
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3920
Mailing Address - Country:US
Mailing Address - Phone:757-466-5283
Mailing Address - Fax:757-466-5849
Practice Address - Street 1:850 KEMPSVILLE RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3920
Practice Address - Country:US
Practice Address - Phone:757-466-5283
Practice Address - Fax:757-466-5849
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024030820363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010132461Medicaid
P15527Medicare UPIN
006585S33Medicare ID - Type Unspecified