Healthcare Provider Details

I. General information

NPI: 1992429484
Provider Name (Legal Business Name): LYNDSIE RAE WRISTON AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYNDSIE RAE THOMAS

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MACCORKLE AVE SE STE 411
CHARLESTON WV
25304-1230
US

IV. Provider business mailing address

15 CLEARVIEW LN
WALLBACK WV
25285-9273
US

V. Phone/Fax

Practice location:
  • Phone: 304-343-4400
  • Fax: 304-345-5005
Mailing address:
  • Phone: 304-880-6232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number114078
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: