Healthcare Provider Details

I. General information

NPI: 1720723422
Provider Name (Legal Business Name): MIKAELA LYNN WOOD PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 04/28/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 HOSPITAL PLZ
CLARKSBURG WV
26301-9316
US

IV. Provider business mailing address

6007 AUTUMN SPRINGS DR
ARLINGTON TX
76001-5002
US

V. Phone/Fax

Practice location:
  • Phone: 304-969-3100
  • Fax:
Mailing address:
  • Phone: 817-789-9648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number112606
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: