Healthcare Provider Details

I. General information

NPI: 1770290926
Provider Name (Legal Business Name): TALITHA NIKOLE WEAVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TALITHA NIKOLE NIELSEN

II. Dates (important events)

Enumeration Date: 10/27/2022
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 N DUTTON AVE
SANTA ROSA CA
95401-4659
US

IV. Provider business mailing address

523 HETTS LN
SEBASTOPOL CA
95472-2727
US

V. Phone/Fax

Practice location:
  • Phone: 707-568-2300
  • Fax:
Mailing address:
  • Phone: 707-953-4866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: