Healthcare Provider Details

I. General information

NPI: 1265705909
Provider Name (Legal Business Name): JERRA LEIGH SHUFF FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 KANAWHA AVE
RAINELLE WV
25962-1013
US

IV. Provider business mailing address

176 MEDICAL CENTER DR
RAINELLE WV
25962-1064
US

V. Phone/Fax

Practice location:
  • Phone: 304-438-6188
  • Fax: 304-438-6819
Mailing address:
  • Phone: 304-438-6188
  • Fax: 304-438-6819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number61894
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: