Healthcare Provider Details

I. General information

NPI: 1942895230
Provider Name (Legal Business Name): MAKAYLA PETERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2021
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 MASON ST
LESTER WV
25865-9583
US

IV. Provider business mailing address

102 MASON ST
LESTER WV
25865-9583
US

V. Phone/Fax

Practice location:
  • Phone: 304-923-2952
  • Fax:
Mailing address:
  • Phone: 304-923-2952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: