MEDICARE: MS. LISA ANN WEAVER FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	79070	TN
2	363LF0000X	Family Nurse Practitioner	6319	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	3710887	OTHER	TN	MEDICARE GROUP NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1659447654	OTHER		NPI GROUP NUMBER

General Provider Information

NPI Number	:	1134124902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA ANN WEAVER FNP-C

Provider Business Mailing Address
First Line	:	104 IVY LN
Second Line	:
City	:	PULASKI
State	:	TN
Zip	:	38478-4550
Country	:	US
Telephone Number	:	931-424-1330
Fax Number	:	931-424-0019

Provider Business Practice Location Address
First Line	:	104 IVY LN
Second Line	:
City	:	PULASKI
State	:	TN
Zip	:	38478-4550
Country	:	US
Telephone Number	:	931-424-1330
Fax Number	:	931-424-0019

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	10/09/2009

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