Healthcare Provider Details

I. General information

NPI: 1770101123
Provider Name (Legal Business Name): KELLY SNYDER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2020
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1599 2ND AVE
CHARLESTON WV
25387-2514
US

IV. Provider business mailing address

1599 2ND AVE
CHARLESTON WV
25387-2514
US

V. Phone/Fax

Practice location:
  • Phone: 304-344-0586
  • Fax: 304-344-0586
Mailing address:
  • Phone: 304-344-0586
  • Fax: 304-344-0586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number75668
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: