Healthcare Provider Details

I. General information

NPI: 1558447805
Provider Name (Legal Business Name): LITTLE BEAVER FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2006
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16130 WEBSTER RD.
CRAIGSVILLE WV
26205-1728
US

IV. Provider business mailing address

PO BOX 1728
CRAIGSVILLE WV
26205-1728
US

V. Phone/Fax

Practice location:
  • Phone: 304-742-3570
  • Fax: 304-742-3572
Mailing address:
  • Phone: 304-742-3570
  • Fax: 304-742-3572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number52802
License Number StateWV

VIII. Authorized Official

Name: CHERYL L WHITE
Title or Position: OWNER/PRESIDENT
Credential: APRN
Phone: 304-742-3570