Healthcare Provider Details

I. General information

NPI: 1053258319
Provider Name (Legal Business Name): AMANDA NICOLE WEISE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6751 N CHESTNUT ST
RAVENNA OH
44266-3903
US

IV. Provider business mailing address

34 CORTLAND CIR
GENEVA OH
44041-9135
US

V. Phone/Fax

Practice location:
  • Phone: 330-296-3641
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: