Healthcare Provider Details

I. General information

NPI: 1831503275
Provider Name (Legal Business Name): GREENBRIER COUNTY BOARD OF HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 09/18/2014
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 TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number37552
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number53104
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number15358
License Number StateWV

VIII. Authorized Official

Name: NIKKI DOLAN
Title or Position: NURSE DIRECTOR
Credential: RN
Phone: 304-645-1787