Provider Demographics
NPI:1881318756
Name:WEAVER, KELLY RAE (CPNP-PC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RAE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1444 SUWANNEE LN
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-8805
Mailing Address - Country:US
Mailing Address - Phone:318-272-3208
Mailing Address - Fax:
Practice Address - Street 1:1 SAINT MARY PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4307
Practice Address - Country:US
Practice Address - Phone:318-272-3208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA226455363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics