MEDICARE: METTA KATHERINE LEE WEAVER APRN, CNM

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	163W00000X	Registered Nurse	54221	ID
2	163W00000X	Registered Nurse	10009959	OR
3	367A00000X	Advanced Practice Midwife	852	NM
4	367A00000X	Advanced Practice Midwife	2023027340	MO
5	367A00000X	Advanced Practice Midwife	13419449-4402	UT
6	367A00000X	Advanced Practice Midwife	54221	ID

General Provider Information

NPI Number	:	1306397088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	METTA KATHERINE LEE WEAVER APRN, CNM

Provider Business Mailing Address
First Line	:	412 E 41ST ST STE 2
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83714-6348
Country	:	US
Telephone Number	:	208-742-4784
Fax Number	:

Provider Business Practice Location Address
First Line	:	412 E 41ST ST STE 2
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83714-6348
Country	:	US
Telephone Number	:	208-742-4784
Fax Number	:

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

Provider Enumeration Date	:	10/18/2016
Last Update Date	:	08/25/2023

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