Healthcare Provider Details

I. General information

NPI: 1598372401
Provider Name (Legal Business Name): CRISTY CUPP NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRISTY LYNN PALMER NP

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 S PENN AVE
HARRISVILLE WV
26362-1371
US

IV. Provider business mailing address

8 MEMORY LN
ELLENBORO WV
26346-6733
US

V. Phone/Fax

Practice location:
  • Phone: 304-643-4005
  • Fax:
Mailing address:
  • Phone: 478-955-6621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN239073
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number108277
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: