Healthcare Provider Details

I. General information

NPI: 1629637293
Provider Name (Legal Business Name): CARLY JEAN WEAVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 03/07/2023
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12470 TELECOM DR STE 300W
TEMPLE TERRACE FL
33637-0904
US

IV. Provider business mailing address

12470 TELECOM DR STE 300W
TEMPLE TERRACE FL
33637-0904
US

V. Phone/Fax

Practice location:
  • Phone: 813-871-8200
  • Fax: 813-357-5501
Mailing address:
  • Phone: 813-871-8183
  • Fax: 813-871-8184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number11001578
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11001578
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: