Provider Demographics
NPI:1417563941
Name:WEAVER, TRACY LYNN (CNP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:WEAVER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6417 STONE CREEK TER
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-1926
Mailing Address - Country:US
Mailing Address - Phone:513-827-0376
Mailing Address - Fax:
Practice Address - Street 1:3101 N TARRANT PKWY
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-8601
Practice Address - Country:US
Practice Address - Phone:817-639-1360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1012889207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine