Healthcare Provider Details

I. General information

NPI: 1467900548
Provider Name (Legal Business Name): KRISTEN ASHLEE HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN ASHLEE ROWE

II. Dates (important events)

Enumeration Date: 09/16/2016
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WHEELING AVE
GLEN DALE WV
26038-1660
US

IV. Provider business mailing address

303 NW 11TH ST
FAIRFIELD IL
62837-1203
US

V. Phone/Fax

Practice location:
  • Phone: 304-845-3211
  • Fax:
Mailing address:
  • Phone: 618-847-8243
  • Fax: 618-847-8387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number717
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: