Provider Demographics
NPI:1720369408
Name:WEAVER, MELINIE M (LMP, MMP)
Entity Type:Individual
Prefix:
First Name:MELINIE
Middle Name:M
Last Name:WEAVER
Suffix:
Gender:F
Credentials:LMP, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 S 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98903-9448
Mailing Address - Country:US
Mailing Address - Phone:571-210-5708
Mailing Address - Fax:
Practice Address - Street 1:2811 S 74TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98903-9448
Practice Address - Country:US
Practice Address - Phone:571-210-5708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60246146174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist