Healthcare Provider Details

I. General information

NPI: 1629972229
Provider Name (Legal Business Name): MISTY DAWN ROYAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 W 4TH AVE
LESTER WV
25865-1204
US

IV. Provider business mailing address

125 W 4TH AVE
LESTER WV
25865-1204
US

V. Phone/Fax

Practice location:
  • Phone: 681-385-1635
  • Fax:
Mailing address:
  • Phone: 681-385-1635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: