Healthcare Provider Details

I. General information

NPI: 1922811363
Provider Name (Legal Business Name): KAYLA MICHELLE ROE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 OHIO AVE
CHARLESTON WV
25302-2212
US

IV. Provider business mailing address

104 ALEX LN
CHARLESTON WV
25304-2952
US

V. Phone/Fax

Practice location:
  • Phone: 681-205-8701
  • Fax: 833-428-4794
Mailing address:
  • Phone: 304-734-2040
  • Fax: 304-734-2047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number121993
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: