Healthcare Provider Details

I. General information

NPI: 1124128905
Provider Name (Legal Business Name): MICHELLE E HUMPHREYS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 PENNSYLVANIA AVE SUITE 304
CHARLESTON WV
25302
US

IV. Provider business mailing address

PO BOX 7000
MORGANTOWN WV
26507-7000
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-1515
  • Fax: 304-388-1570
Mailing address:
  • Phone: 304-347-1290
  • Fax: 304-347-1397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number41918
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: