=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366909426
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTIN MICHELE WEAVER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2019
-----------------------------------------------------
Last Update Date | 02/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 425 WESTMINSTER AVE
-----------------------------------------------------
City | HANOVER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17331-9141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-637-4166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2928 LOMAN AVE
-----------------------------------------------------
City | YORK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17408-9476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-792-1663
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | TEI000063
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------