Healthcare Provider Details

I. General information

NPI: 1174913214
Provider Name (Legal Business Name): KATRINA WASMUTH NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2015
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 WHEELING AVE
GLEN DALE WV
26038-1536
US

IV. Provider business mailing address

472 LAUREN LN
GLEN EASTON WV
26039-1475
US

V. Phone/Fax

Practice location:
  • Phone: 304-845-1500
  • Fax:
Mailing address:
  • Phone: 304-551-1780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number52290
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number52290
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: