Healthcare Provider Details

I. General information

NPI: 1295214583
Provider Name (Legal Business Name): RICKELL JEAN LUSK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 12/01/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 FLAT TOP ROAD
GHENT WV
25843
US

IV. Provider business mailing address

1844 HARPER RD
BECKLEY WV
25801-3366
US

V. Phone/Fax

Practice location:
  • Phone: 681-238-0644
  • Fax:
Mailing address:
  • Phone: 304-250-0307
  • Fax: 304-250-0384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number81121
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: