Healthcare Provider Details

I. General information

NPI: 1093284937
Provider Name (Legal Business Name): PHOENIX RISING HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 ERWIN LN STE A
FAIRMONT WV
26554-1376
US

IV. Provider business mailing address

PO BOX 1286
FAIRMONT WV
26555-1286
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-0111
  • Fax: 304-366-2099
Mailing address:
  • Phone: 304-366-0111
  • Fax: 304-366-2099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MISS TRACI TANNEHILL
Title or Position: MANAGING MEMBER OF LLC
Credential: APRN
Phone: 304-366-0111