Healthcare Provider Details

I. General information

NPI: 1134724826
Provider Name (Legal Business Name): REGENEA QUICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 HOSPITAL DR
LOGAN WV
25601-3452
US

IV. Provider business mailing address

20 HOSPITAL DR
LOGAN WV
25601-3452
US

V. Phone/Fax

Practice location:
  • Phone: 304-831-1891
  • Fax: 304-831-1892
Mailing address:
  • Phone: 304-831-1891
  • Fax: 304-831-1892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number107920
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number58649
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: