Healthcare Provider Details

I. General information

NPI: 1114671906
Provider Name (Legal Business Name): TAKARA LEEANN MUNCY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 LMAH CENTER RD
LOGAN WV
25601-4058
US

IV. Provider business mailing address

174 LMAH CENTER RD
LOGAN WV
25601-4058
US

V. Phone/Fax

Practice location:
  • Phone: 304-792-7130
  • Fax: 304-792-7146
Mailing address:
  • Phone: 304-792-7130
  • Fax: 304-792-7146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number112055
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: