Healthcare Provider Details

I. General information

NPI: 1275110066
Provider Name (Legal Business Name): MONA DIVERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 03/26/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1157 BOLT RD
FAIRDALE WV
25839
US

IV. Provider business mailing address

PO BOX 711
GLEN DANIEL WV
25844-0711
US

V. Phone/Fax

Practice location:
  • Phone: 681-459-3155
  • Fax:
Mailing address:
  • Phone: 681-459-3115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: