Healthcare Provider Details

I. General information

NPI: 1265169627
Provider Name (Legal Business Name): MARA MARIE VAN FOSSEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2022
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WELDAY AVE
WINTERSVILLE OH
43953-3779
US

IV. Provider business mailing address

PO BOX 779
MORGANTOWN WV
26507-0779
US

V. Phone/Fax

Practice location:
  • Phone: 740-264-5770
  • Fax:
Mailing address:
  • Phone: 304-797-6200
  • Fax: 304-797-6306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number113947
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0031865
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: