Healthcare Provider Details

I. General information

NPI: 1750553632
Provider Name (Legal Business Name): MOLLY JO WEAVER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MOLLY JO WENGER

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 01/26/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 N HIGH ST #110
DENVER CO
80205-5503
US

IV. Provider business mailing address

4900 S MONACO ST SUITE 210
DENVER CO
80237-3486
US

V. Phone/Fax

Practice location:
  • Phone: 303-301-9019
  • Fax: 303-861-6254
Mailing address:
  • Phone: 303-301-9019
  • Fax: 303-861-6254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5318
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: