Healthcare Provider Details

I. General information

NPI: 1366111825
Provider Name (Legal Business Name): CLARISSA CARNELL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 SUNRISE BLVD
ROMNEY WV
26757-6345
US

IV. Provider business mailing address

10790 FORT ASHBY RD
KEYSER WV
26726-6229
US

V. Phone/Fax

Practice location:
  • Phone: 304-822-7527
  • Fax:
Mailing address:
  • Phone: 304-813-6597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number002760
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: