Provider Demographics
NPI:1831140508
Name:WEAVER, BEVERLY P (RN, MSN, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:P
Last Name:WEAVER
Suffix:
Gender:F
Credentials:RN, MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1015
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632
Mailing Address - Country:US
Mailing Address - Phone:662-429-4988
Mailing Address - Fax:662-429-4966
Practice Address - Street 1:3451 GOODMAN RD E
Practice Address - Street 2:STE 115
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9303
Practice Address - Country:US
Practice Address - Phone:662-890-5555
Practice Address - Fax:662-890-8899
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR629189363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122952Medicaid
MS00122952Medicaid
MS500002994Medicare PIN