MEDICARE: MRS. JOHNNIE LOIS WEASE NP

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	363LW0102X	Women's Health Nurse Practitioner	9942	SC

General Provider Information

NPI Number	:	1316935547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOHNNIE LOIS WEASE NP

Provider Business Mailing Address
First Line	:	1179 ROYAL LINKS DR
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-6937
Country	:	US
Telephone Number	:	843-971-9566
Fax Number	:	843-971-9566

Provider Business Practice Location Address
First Line	:	1189 IRON BRIDGE DR
Second Line	:	#100
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-7401
Country	:	US
Telephone Number	:	843-856-1210
Fax Number	:

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

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	07/08/2007

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