Provider Demographics
NPI:1790368157
Name:WEAVER, TRACI NICOLE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:NICOLE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11250 HEIDI JANE LN
Mailing Address - Street 2:
Mailing Address - City:FOWLERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48836-8704
Mailing Address - Country:US
Mailing Address - Phone:517-294-7553
Mailing Address - Fax:
Practice Address - Street 1:11250 HEIDI JANE LN
Practice Address - Street 2:
Practice Address - City:FOWLERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48836-8704
Practice Address - Country:US
Practice Address - Phone:517-294-7553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704272016367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered