Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XG0600X | Occupational Therapist - Gerontology | OC015754 | PA |
NPI | 1669933537 |
---|---|
Provider Name | Mrs. Kylie Jayde Weaver |
First Address | Ephrata, PA 17522-2150 |
Second Address | York, PA 17404-1771 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/03/2019 |
Last Update Date | 25/03/2019 |