Provider Demographics
NPI:1770290926
Name:WEAVER, TALITHA NIKOLE
Entity type:Individual
Prefix:
First Name:TALITHA
Middle Name:NIKOLE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TALITHA
Other - Middle Name:NIKOLE
Other - Last Name:NIELSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:523 HETTS LN
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-2727
Mailing Address - Country:US
Mailing Address - Phone:707-953-4866
Mailing Address - Fax:
Practice Address - Street 1:1260 N DUTTON AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4659
Practice Address - Country:US
Practice Address - Phone:707-568-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No172V00000XOther Service ProvidersCommunity Health Worker