Healthcare Provider Details

I. General information

NPI: 1487565628
Provider Name (Legal Business Name): KRISTIN ROSE DIXOM LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

788 CIRCLEVIEW DR
BECKLEY WV
25801-8408
US

IV. Provider business mailing address

601 VENTURE DR STE 200
MORGANTOWN WV
26508-7310
US

V. Phone/Fax

Practice location:
  • Phone: 304-923-7547
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number36079
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: