Healthcare Provider Details

I. General information

NPI: 1528609856
Provider Name (Legal Business Name): JAN AUGUSTA NIEVES PMHNP-BC (APRN)
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3094 CHARLESTOWN ROAD
KEARNEYSVILLE WV
25430
US

IV. Provider business mailing address

1408 NORTH ST
MARTINSBURG WV
25401-2067
US

V. Phone/Fax

Practice location:
  • Phone: 304-901-2070
  • Fax:
Mailing address:
  • Phone: 443-333-3996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number104701
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: