Provider Demographics
NPI:1750553632
Name:WEAVER, MOLLY JO (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:JO
Last Name:WEAVER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:JO
Other - Last Name:WENGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4900 S MONACO ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:303-301-9019
Mailing Address - Fax:303-861-6254
Practice Address - Street 1:2055 N HIGH ST
Practice Address - Street 2:#110
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5503
Practice Address - Country:US
Practice Address - Phone:303-301-9019
Practice Address - Fax:303-861-6254
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5318363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200743430AMedicaid
WY1750553632Medicaid
SD1750553632Medicaid
NE10025887900Medicaid
CO60871334Medicaid