Healthcare Provider Details

I. General information

NPI: 1528476793
Provider Name (Legal Business Name): KACIE OWENS PPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 PENNSLYVANIA AVENUE SUITE 103
CHARLESTON WV
25302-3389
US

IV. Provider business mailing address

PO BOX 124
ELEANOR WV
25070-0124
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-1552
  • Fax:
Mailing address:
  • Phone: 304-542-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN78736-CPNP
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: