Individual
KELLY RAE WEAVER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CPNP-PC
Contact information
Practice address
1 SAINT MARY PL, SHREVEPORT, LA 71101-4307
(318) 272-3208
Mailing address
1444 SUWANNEE LN, BENTON, LA 71006-8805
(318) 272-3208
Taxonomy
Speciality
Code
Description
License number
State
363LP0200X
Pediatric Nurse Practitioner
Primary
226455
LA
Other
Enumeration date
10/03/2022
Last updated
10/04/2022
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