Healthcare Provider Details

I. General information

NPI: 1760647929
Provider Name (Legal Business Name): HEIDI E DOLIN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2008
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 ELIZABETH HWY
FAYETTEVILLE WV
25840
US

IV. Provider business mailing address

439 ELIZABETH HWY
FAYETTEVILLE WV
25840
US

V. Phone/Fax

Practice location:
  • Phone: 304-574-2600
  • Fax: 304-574-2951
Mailing address:
  • Phone: 304-574-2600
  • Fax: 304-574-2951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number43508
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: