Healthcare Provider Details

I. General information

NPI: 1003639865
Provider Name (Legal Business Name): ROBERT ZICKAFOOSE FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2024
Last Update Date: 10/31/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 MADISON AVE
MADISON WV
25130-1669
US

IV. Provider business mailing address

2172 UPPER CRAWLEY CREEK RD
CHAPMANVILLE WV
25508-7178
US

V. Phone/Fax

Practice location:
  • Phone: 304-369-1230
  • Fax:
Mailing address:
  • Phone: 304-953-3974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number121153
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: