Healthcare Provider Details

I. General information

NPI: 1427126929
Provider Name (Legal Business Name): KELLY JO SHUMAN MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 CIMARRON RD
NUTTER FORT WV
26301-4374
US

IV. Provider business mailing address

135 CIMARRON RD
NUTTER FORT WV
26301-4374
US

V. Phone/Fax

Practice location:
  • Phone: 304-623-5551
  • Fax: 304-623-5552
Mailing address:
  • Phone: 304-623-5551
  • Fax: 304-623-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2000-479
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: