Healthcare Provider Details

I. General information

NPI: 1457585234
Provider Name (Legal Business Name): LYDIA M WEAVER APRN-CNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2009
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 KNOX ABBOTT DR STE 400
CAYCE SC
29033-4353
US

IV. Provider business mailing address

5439 BURKHARDT RD
DAYTON OH
45431-2111
US

V. Phone/Fax

Practice location:
  • Phone: 843-501-1099
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.335652
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0033630
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number28264
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: