=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790904191
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DARLA JOAN WEAVER PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2007
-----------------------------------------------------
Last Update Date | 07/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1414 S ELM ST
-----------------------------------------------------
City | PARIS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72855-4924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-963-6151
-----------------------------------------------------
Fax | 479-963-3331
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 227 DUBBS WAY
-----------------------------------------------------
City | BOONEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72927-7849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-675-2898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number | PT1447
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT1447
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------