Healthcare Provider Details

I. General information

NPI: 1073436994
Provider Name (Legal Business Name): HALEY JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 HOSPITAL DR STE 100
LOGAN WV
25601-3451
US

IV. Provider business mailing address

280 RIGHT FORK BENS CREEK ROAD 280 RIGHT FORK BENS CREEK ROAD
WHARNCLIFFE WV
25651
US

V. Phone/Fax

Practice location:
  • Phone: 304-896-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number127017
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: