Provider Demographics
NPI:1134124902
Name:WEAVER, LISA ANN (FNP-C)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:WEAVER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 IVY LN
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478-4550
Mailing Address - Country:US
Mailing Address - Phone:931-424-1330
Mailing Address - Fax:931-424-0019
Practice Address - Street 1:104 IVY LN
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-4550
Practice Address - Country:US
Practice Address - Phone:931-424-1330
Practice Address - Fax:931-424-0019
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN79070363LF0000X
TN6319363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3344019Medicaid
TN3710887OtherMEDICARE GROUP NUMBER
1659447654OtherNPI GROUP NUMBER
TNP00158812Medicare PIN
1659447654OtherNPI GROUP NUMBER