Healthcare Provider Details

I. General information

NPI: 1508073784
Provider Name (Legal Business Name): DIANE SMITH LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 PHILPOT LANE
BEAVER WV
25813
US

IV. Provider business mailing address

PO BOX 274
GLEN JEAN WV
25846-0274
US

V. Phone/Fax

Practice location:
  • Phone: 304-254-9262
  • Fax:
Mailing address:
  • Phone: 304-469-2652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number27398
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: