Healthcare Provider Details

I. General information

NPI: 1417147091
Provider Name (Legal Business Name): MARY ELLEN WIMER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 PINE STREET
FRANKLIN WV
26807-0100
US

IV. Provider business mailing address

PO BOX 100 314 PINE STREET
FRANKLIN WV
26807-0100
US

V. Phone/Fax

Practice location:
  • Phone: 304-358-2355
  • Fax: 304-358-3054
Mailing address:
  • Phone: 304-358-2355
  • Fax: 304-358-3054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number39542
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: