Healthcare Provider Details

I. General information

NPI: 1639807969
Provider Name (Legal Business Name): NATASHA NICOLE KOWALCZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 COLLIERS WAY STE 511
WEIRTON WV
26062-5054
US

IV. Provider business mailing address

2930 MCKIMS RIDGE RD
COLLIERS WV
26035-1296
US

V. Phone/Fax

Practice location:
  • Phone: 304-723-6801
  • Fax:
Mailing address:
  • Phone: 304-374-2719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number114578
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number89228
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: