Provider Demographics
NPI:1801422845
Name:WEAVER, MIRANDA LOUISE-KREISER (AGNP)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LOUISE-KREISER
Last Name:WEAVER
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:L
Other - Last Name:KREISER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:818 W KING ST STE 201
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2117
Mailing Address - Country:US
Mailing Address - Phone:989-723-3168
Mailing Address - Fax:989-725-2962
Practice Address - Street 1:818 W KING ST STE 201
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2117
Practice Address - Country:US
Practice Address - Phone:989-723-3168
Practice Address - Fax:989-725-2962
Is Sole Proprietor?:No
Enumeration Date:2020-03-22
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAG01200149363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1801422845Medicaid