=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114215779
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TONYA RACHEL YOUNG FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2011
-----------------------------------------------------
Last Update Date | 02/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10003 WEBSTER RD
-----------------------------------------------------
City | CAMDEN ON GAULEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26208-7713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-226-5725
-----------------------------------------------------
Fax | 304-226-3274
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10003 WEBSTER RD
-----------------------------------------------------
City | CAMDEN ON GAULEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26208-7713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-226-5725
-----------------------------------------------------
Fax | 304-226-3274
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 72424
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------