Provider Demographics
NPI:1649770397
Name:WEAVER, BIANCA GRACIELA (CNM)
Entity Type:Individual
Prefix:MRS
First Name:BIANCA
Middle Name:GRACIELA
Last Name:WEAVER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5754
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:9880 ANGIES WAY STE 350
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2852
Practice Address - Country:US
Practice Address - Phone:502-423-9595
Practice Address - Fax:502-719-0161
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012061176B00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300013135Medicaid
KY7100516470Medicaid