Provider Demographics
NPI:1720799455
Name:WEAVER, CORLANDRA LACRYSTAL
Entity Type:Individual
Prefix:
First Name:CORLANDRA
Middle Name:LACRYSTAL
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 6TH ST E
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404-3114
Mailing Address - Country:US
Mailing Address - Phone:205-887-0799
Mailing Address - Fax:
Practice Address - Street 1:2428 6TH ST E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-3114
Practice Address - Country:US
Practice Address - Phone:205-887-0799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9372691172A00000X, 343900000X
AL650418160035246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty