Provider Demographics
NPI:1124423173
Name:WEAVER, REGINA (LPN)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 DRIVING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14613-1932
Mailing Address - Country:US
Mailing Address - Phone:585-732-3768
Mailing Address - Fax:
Practice Address - Street 1:434 DRIVING PARK AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14613-2310
Practice Address - Country:US
Practice Address - Phone:585-732-3768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-01
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY285506164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid