Healthcare Provider Details

I. General information

NPI: 1598184384
Provider Name (Legal Business Name): TIA HUMPHREYS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9207 SENECA TRL
RONCEVERTE WV
24970-1328
US

IV. Provider business mailing address

9207 SENECA TRL
RONCEVERTE WV
24970-1328
US

V. Phone/Fax

Practice location:
  • Phone: 304-645-1787
  • Fax: 304-645-3630
Mailing address:
  • Phone: 304-645-1787
  • Fax: 304-645-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number24712
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: