Healthcare Provider Details

I. General information

NPI: 1326953969
Provider Name (Legal Business Name): MOUNTAIN GRACE WOMEN'S WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 MERCHANT ST STE 1
FAIRMONT WV
26554-4042
US

IV. Provider business mailing address

354 HARBOR DR
MORGANTOWN WV
26508-9227
US

V. Phone/Fax

Practice location:
  • Phone: 304-504-3994
  • Fax:
Mailing address:
  • Phone: 304-694-8474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DEANNE DYSON
Title or Position: OWNER/PROVIDER
Credential: FNP-BC
Phone: 304-694-8474