Healthcare Provider Details

I. General information

NPI: 1144744582
Provider Name (Legal Business Name): DANA FRANCES DEGEORGE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANA F. KENNEDY

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVE SE
CHARLESTON WV
25304-1227
US

IV. Provider business mailing address

3412 STAUNTON AVE SE
CHARLESTON WV
25304-1327
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-4172
  • Fax: 304-388-4155
Mailing address:
  • Phone: 304-388-6004
  • Fax: 304-388-3360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2061
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: