Healthcare Provider Details

I. General information

NPI: 1043121205
Provider Name (Legal Business Name): GRACEFULLY RENEWED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 ALFORD BR
HARTS WV
25524-8700
US

IV. Provider business mailing address

74 ALFORD BR
HARTS WV
25524-8700
US

V. Phone/Fax

Practice location:
  • Phone: 304-305-3662
  • Fax:
Mailing address:
  • Phone: 304-305-3662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHASSITY R KIRK
Title or Position: NURSE PRACTITIONER
Credential: APRN,FNP-BC
Phone: 304-305-3662