Healthcare Provider Details

I. General information

NPI: 1356646087
Provider Name (Legal Business Name): ROBERTA CHRISTINE WEAVER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ROBERTA CHRISTINE RUSSELL

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 BROADWAY
LUBBOCK TX
79401-3206
US

IV. Provider business mailing address

1313 BROADWAY STE 5
LUBBOCK TX
79401-3209
US

V. Phone/Fax

Practice location:
  • Phone: 806-765-2611
  • Fax: 806-765-6271
Mailing address:
  • Phone: 806-765-2611
  • Fax: 806-687-5957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number648686
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP119780
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: