Healthcare Provider Details

I. General information

NPI: 1124049770
Provider Name (Legal Business Name): ANGELITA NIXON, CNM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 SCENIC DR
SCOTT DEPOT WV
25560-9656
US

IV. Provider business mailing address

PO BOX 213
SCOTT DEPOT WV
25560-0213
US

V. Phone/Fax

Practice location:
  • Phone: 304-757-9006
  • Fax:
Mailing address:
  • Phone: 304-757-9006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number110
License Number StateWV

VIII. Authorized Official

Name: ANGELITA NIXON
Title or Position: MANAGING MEMBER
Credential: CNM, MSN
Phone: 304-757-9006