Provider Demographics
NPI:1215695366
Name:WEAVER, NICKOL (FNP-C)
Entity type:Individual
Prefix:
First Name:NICKOL
Middle Name:
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 1:6020 RICHMOND HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22303-2157
Mailing Address - Country:US
Mailing Address - Phone:410-977-5128
Mailing Address - Fax:
Practice Address - Street 1:25 CROSSROADS DR STE 10
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5473
Practice Address - Country:US
Practice Address - Phone:410-415-5105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR187292363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily