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General NPI Number Information
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NPI Number | 1548823628
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Entity Type | Individual
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Provider Name | JENNA M BAIN CRNP
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Gender | Female
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Dates
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Enumeration Date | 04/15/2019
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Last Update Date | 01/02/2025
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Provider Practice Location Address
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Address Line | 1320 MAPLEWOOD AVE
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City | RONCEVERTE
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State | WV
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Zip | 24970-8016
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Country | US
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Telephone | 304-647-6006
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Fax |
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Provider Business Mailing Address
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Address Line | 501 MORRIS ST
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City | CHARLESTON
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State | WV
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Zip | 25301-1326
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Country | US
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Telephone | 304-647-6006
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 105700
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 4019424
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License Number State | KY
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