Provider Demographics
NPI:1306037197
Name:WEAVER, DIANNE MARIE (DOM)
Entity type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:MARIE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:996 CALLE KATARINA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-5008
Mailing Address - Country:US
Mailing Address - Phone:505-424-3087
Mailing Address - Fax:
Practice Address - Street 1:1919 5TH ST
Practice Address - Street 2:SUITE N
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5402
Practice Address - Country:US
Practice Address - Phone:505-699-6468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM884171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist