Healthcare Provider Details

I. General information

NPI: 1427703636
Provider Name (Legal Business Name): VALENA REENA KIDD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 CRYSTAL MOUNTAIN LN
POOL WV
26684-9754
US

IV. Provider business mailing address

188 CRYSTAL MOUNTAIN LN
POOL WV
26684-9754
US

V. Phone/Fax

Practice location:
  • Phone: 304-880-0838
  • Fax:
Mailing address:
  • Phone: 304-880-0838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number81078
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: