=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942980339
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY DEANE HARPER PMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2023
-----------------------------------------------------
Last Update Date | 04/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 PROFESSIONAL PL STE 101
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26330-4599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-460-5123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 502 BARLEY CT
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26330-6218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-941-8243
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 117587
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------