Healthcare Provider Details

I. General information

NPI: 1164713186
Provider Name (Legal Business Name): MS. KELLY M WEAVER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2011
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17915 WILDCAT RD
DANVILLE OH
43014-9560
US

IV. Provider business mailing address

17915 WILDCAT RD
DANVILLE OH
43014-9560
US

V. Phone/Fax

Practice location:
  • Phone: 740-504-2359
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN120946
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: