Healthcare Provider Details

I. General information

NPI: 1194103994
Provider Name (Legal Business Name): JEREMY MCDANIEL FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2015
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3729 TEAYS VALLEY RD
HURRICANE WV
25526-9705
US

IV. Provider business mailing address

2585 3RD AVE
HUNTINGTON WV
25703-1642
US

V. Phone/Fax

Practice location:
  • Phone: 304-760-6042
  • Fax: 304-760-6042
Mailing address:
  • Phone: 304-781-5159
  • Fax: 304-697-2086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN64727NP
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number64727
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: