Healthcare Provider Details

I. General information

NPI: 1518034784
Provider Name (Legal Business Name): MARILYN MARGARITA WEAVER REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2126 MARSTON LN
FLOSSMOOR IL
60422-1334
US

IV. Provider business mailing address

2126 MARSTON LANE
FLOSSMOOR IL
60422-1334
US

V. Phone/Fax

Practice location:
  • Phone: 708-798-2322
  • Fax:
Mailing address:
  • Phone: 708-798-2322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number041-211924
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: