Provider Demographics
NPI:1629610134
Name:WEAVER, ALICIA LYNN (MS, RD, CSP, LD)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:LYNN
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MS, RD, CSP, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 PLEASANT PLACE DR
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29907-1188
Mailing Address - Country:US
Mailing Address - Phone:843-228-5194
Mailing Address - Fax:
Practice Address - Street 1:1 PINCKNEY BLVD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6122
Practice Address - Country:US
Practice Address - Phone:843-228-5194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1779133V00000X
NCL005657133V00000X
86003530133VN1004X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric