Healthcare Provider Details

I. General information

NPI: 1437650504
Provider Name (Legal Business Name): SHEA RAE DAWN HOFFMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2018
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 COLLEGE ST
BARBOURVILLE KY
40906-1410
US

IV. Provider business mailing address

5207 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1009
US

V. Phone/Fax

Practice location:
  • Phone: 606-546-1303
  • Fax:
Mailing address:
  • Phone: 304-552-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberTCA679
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: