Healthcare Provider Details

I. General information

NPI: 1649096330
Provider Name (Legal Business Name): TAYLOR RAEANNE HAIR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2024
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 MAIN ST STE 104
WHEELING WV
26003-2737
US

IV. Provider business mailing address

69 STONE CREEK RD
COLLIERS WV
26035-1538
US

V. Phone/Fax

Practice location:
  • Phone: 304-513-3495
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2989
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.009346RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: