Provider Demographics
NPI:1922204551
Name:WEAVER, MELODY ANN (PHD FNP)
Entity Type:Individual
Prefix:DR
First Name:MELODY
Middle Name:ANN
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PHD FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 S 8TH AVE STOP 8101
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0001
Mailing Address - Country:US
Mailing Address - Phone:208-282-5994
Mailing Address - Fax:208-282-4476
Practice Address - Street 1:921 S 8TH AVE STOP 8101
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209
Practice Address - Country:US
Practice Address - Phone:208-282-5994
Practice Address - Fax:208-282-4476
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP10764363LF0000X
ID55023363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily