MEDICARE: ANN MARIE WEAVER RD

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	133V00000X	Registered Dietitian	1035016

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1035016	OTHER		COMMISSION ON DIETETIC REGISTRATION

General Provider Information

NPI Number	:	1174281885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANN MARIE WEAVER RD

Provider Business Mailing Address
First Line	:	2217 N POWER RD APT 3030
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85215-2983
Country	:	US
Telephone Number	:	417-379-3355
Fax Number	:

Provider Business Practice Location Address
First Line	:	2217 N POWER RD APT 3030
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85215-2983
Country	:	US
Telephone Number	:	417-379-3355
Fax Number	:

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

Provider Enumeration Date	:	11/30/2021
Last Update Date	:	11/30/2021

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Directions to “ ANN MARIE WEAVER RD” Practice Location

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