Healthcare Provider Details

I. General information

NPI: 1558531368
Provider Name (Legal Business Name): TRENA KISH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 MAIN ST
MADISON WV
25130-1417
US

IV. Provider business mailing address

97 GREAT TEAYS BLVD STE 6
SCOTT DEPOT WV
25560-9816
US

V. Phone/Fax

Practice location:
  • Phone: 304-369-0393
  • Fax: 304-369-0371
Mailing address:
  • Phone: 304-757-6999
  • Fax: 304-201-5019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number57283
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number104680
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: