Healthcare Provider Details

I. General information

NPI: 1891332151
Provider Name (Legal Business Name): NICOLE WEAVER LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CASHELL FOOTBALL CENTER / MS 265
RENO NV
89557-0265
US

IV. Provider business mailing address

CASHELL FOOTBALL CENTER / MS 265
RENO NV
89557-0265
US

V. Phone/Fax

Practice location:
  • Phone: 775-784-3507
  • Fax: 775-784-8077
Mailing address:
  • Phone: 775-784-3507
  • Fax: 775-784-8077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: