Basic Information
| Provider Information | |||||||||
| NPI: | 1760031769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | HALEY | ||||||||
| MiddleName: | ANNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16782 VON KARMAN AVE STE 11 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926062417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9498332237 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3731 6TH AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921034383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192780884 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2019 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/18/2022 | ||||||||
| NPIReactivationDate: | 06/08/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.