Healthcare Provider Details

I. General information

NPI: 1063404804
Provider Name (Legal Business Name): EDITH ELAINE WEATHERFORD CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 W FAIR AVE #226
MARQUETTE MI
49855-2675
US

IV. Provider business mailing address

1414 W FAIR AVE #226
MARQUETTE MI
49855-2675
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-3925
  • Fax: 906-225-4838
Mailing address:
  • Phone: 906-225-3925
  • Fax: 906-225-4838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704161015
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: