Healthcare Provider Details

I. General information

NPI: 1417462896
Provider Name (Legal Business Name): CAROL KAY FULLER PCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. CAROL KAY SOWARDS

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 12/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 CHESTNUT STREET
KENOVA WV
25530
US

IV. Provider business mailing address

925 CHESTNUT STREET
KENOVA WV
25530
US

V. Phone/Fax

Practice location:
  • Phone: 304-453-4296
  • Fax:
Mailing address:
  • Phone: 304-356-4562
  • Fax: 304-558-4563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: