Healthcare Provider Details

I. General information

NPI: 1942805304
Provider Name (Legal Business Name): BEULAH LYNN ICE-CROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 MARKET ST
PARKERSBURG WV
26101-4323
US

IV. Provider business mailing address

1712 VALLEY MILLS RD
WAVERLY WV
26184-3358
US

V. Phone/Fax

Practice location:
  • Phone: 304-865-5420
  • Fax: 304-865-5423
Mailing address:
  • Phone: 304-488-6828
  • Fax: 304-471-2488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: