MEDICARE: LEAH GABRIELLE HETHERINGTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator		WV

General Provider Information

NPI Number	:	1619831864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEAH GABRIELLE HETHERINGTON

Provider Business Mailing Address
First Line	:	2457 KINGMONT RD
Second Line	:
City	:	FAIRMONT
State	:	WV
Zip	:	26554-8213
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2457 KINGMONT RD
Second Line	:
City	:	FAIRMONT
State	:	WV
Zip	:	26554-8213
Country	:	US
Telephone Number	:	304-677-0804
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2025
Last Update Date	:	12/11/2025

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