Healthcare Provider Details

I. General information

NPI: 1477276897
Provider Name (Legal Business Name): ANGELA M ELLIS-LIVELY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 MALLARD CT
BECKLEY WV
25801-3664
US

IV. Provider business mailing address

101 BILL BAKER WAY
BECKLEY WV
25801-1505
US

V. Phone/Fax

Practice location:
  • Phone: 304-252-8409
  • Fax:
Mailing address:
  • Phone: 304-252-8324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberBP00944946
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: