Provider Demographics
NPI:1598730632
Name:WEISS, MARYLOU M (NP)
Entity type:Individual
Prefix:MS
First Name:MARYLOU
Middle Name:M
Last Name:WEISS
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 KINGSBOROUGH SQ STE 101
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4999
Mailing Address - Country:US
Mailing Address - Phone:757-842-4481
Mailing Address - Fax:
Practice Address - Street 1:1301 EXECUTIVE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3671
Practice Address - Country:US
Practice Address - Phone:757-312-3132
Practice Address - Fax:757-312-6212
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024030820363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010132461Medicaid
P15527Medicare UPIN
006585S33Medicare ID - Type Unspecified