Provider Demographics
NPI:1851927198
Name:WEAVER, TUNDRA NICOLE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:TUNDRA
Middle Name:NICOLE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 BERTRAM LN SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-4138
Mailing Address - Country:US
Mailing Address - Phone:678-249-8121
Mailing Address - Fax:
Practice Address - Street 1:1301 PUNCHBOWL ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2402
Practice Address - Country:US
Practice Address - Phone:808-691-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-2907363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty