=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295504264
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE WEATHERBY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/01/2024
-----------------------------------------------------
Last Update Date | 01/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 HIGHWAY 95 STE 200
-----------------------------------------------------
City | BULLHEAD CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86429-5005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-754-3950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4053 N LAGUNA RD
-----------------------------------------------------
City | GOLDEN VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86413-8947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 003326
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------