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General NPI Number Information
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NPI Number | 1295228161
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Entity Type | Organization
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Legal Business Name | BRUCETON FAMILY MEDICINE LLC
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Dates
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Enumeration Date | 06/14/2018
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Last Update Date | 07/05/2018
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Provider Practice Location Address
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Address Line | 198 MORGANTOWN ST STE 2
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City | BRUCETON MILLS
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State | WV
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Zip | 26525
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Country | US
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Telephone | 304-379-7600
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Fax | 304-379-7599
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Provider Business Mailing Address
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Address Line | PO BOX 442
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City | BRUCETON MILLS
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State | WV
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Zip | 26525-0442
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Country | US
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Telephone | 304-379-7600
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Fax | 304-379-7599
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Authorized Official
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Title or Position | OWNER/NURSE PRACTITIONER
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Name | MRS. ALYSIA FUNK
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Credential | APRN,FNP-BC
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Telephone | 304-379-7600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 81124
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 52464
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License Number State | WV
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