=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326953969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOUNTAIN GRACE WOMEN'S WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2026
-----------------------------------------------------
Last Update Date | 08/18/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 MERCHANT ST STE 1
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26554-4042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-504-3994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 354 HARBOR DR
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26508-9227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-694-8474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | DEANNE DYSON
-----------------------------------------------------
Credential | FNP-BC
-----------------------------------------------------
Telephone | 304-694-8474
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------