Healthcare Provider Details

I. General information

NPI: 1124217864
Provider Name (Legal Business Name): STEPHANIE A. ELMORE OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 DAVIS STUART ROAD
RONCEVERTE WV
24970
US

IV. Provider business mailing address

111 DAVIS STUART ROAD
RONCEVERTE WV
24970
US

V. Phone/Fax

Practice location:
  • Phone: 304-647-3987
  • Fax: 304-647-3990
Mailing address:
  • Phone: 304-647-3987
  • Fax: 304-647-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1341
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: