Healthcare Provider Details

I. General information

NPI: 1386895894
Provider Name (Legal Business Name): KRISTEN M WEAVER M.S., P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 GALAXY DR NE
LACEY WA
98516
US

IV. Provider business mailing address

11711 NE 12TH ST STE 3A
BELLEVUE WA
98005-2461
US

V. Phone/Fax

Practice location:
  • Phone: 360-456-1444
  • Fax:
Mailing address:
  • Phone: 425-450-9474
  • Fax: 425-452-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501011977
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60041800
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: