Healthcare Provider Details

I. General information

NPI: 1932796745
Provider Name (Legal Business Name): ANITA SUE ICE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2020
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 NORWAY LOOP RD
FAIRMONT WV
26554-8024
US

IV. Provider business mailing address

301 SCOTT AVE
MORGANTOWN WV
26508-8804
US

V. Phone/Fax

Practice location:
  • Phone: 304-612-2674
  • Fax:
Mailing address:
  • Phone: 304-296-1731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: