=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619894300
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEANNA VAN STAVOREN OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2026
-----------------------------------------------------
Last Update Date | 07/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 147 SYCAMORE ST
-----------------------------------------------------
City | PIKEVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41501-9118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-218-5511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1619 WAR FORK RD
-----------------------------------------------------
City | VANSANT
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24656-8524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-312-0729
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2494DT
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------