Healthcare Provider Details

I. General information

NPI: 1336690080
Provider Name (Legal Business Name): EMILY WEAVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5623 PULPIT PEAK VW
COLORADO SPRINGS CO
80918-3954
US

IV. Provider business mailing address

7331 GLENBURN DR
FOUNTAIN CO
80817-4087
US

V. Phone/Fax

Practice location:
  • Phone: 316-644-3071
  • Fax:
Mailing address:
  • Phone: 316-644-0371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.0002253
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: