Provider Demographics
NPI:1821115015
Name:WEAVER, KELLY ANN (RN, MSF, FNP, ARNP-C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:WEAVER
Suffix:
Gender:F
Credentials:RN, MSF, FNP, ARNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:13660 JOG ROAD SUITE 2
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-3806
Mailing Address - Country:US
Mailing Address - Phone:561-600-2408
Mailing Address - Fax:561-600-2414
Practice Address - Street 1:4600 MILITARY TRAIL
Practice Address - Street 2:SUITE 218
Practice Address - City:JUPITAR
Practice Address - State:FL
Practice Address - Zip Code:33458
Practice Address - Country:US
Practice Address - Phone:561-626-9041
Practice Address - Fax:561-626-9634
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY413453163W00000X
NYF330977363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03314050Medicaid
NY03314050Medicaid