Healthcare Provider Details

I. General information

NPI: 1740899046
Provider Name (Legal Business Name): LIZZIE MARIE GILLENWATER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 N RED OAK DR
COTTAGEVILLE WV
25239-9777
US

IV. Provider business mailing address

131 N RED OAK DR
COTTAGEVILLE WV
25239-9777
US

V. Phone/Fax

Practice location:
  • Phone: 304-531-9992
  • Fax:
Mailing address:
  • Phone: 304-531-9992
  • Fax: 304-273-5131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: