1003203316 NPI number — NICOLE RADABAUGH FNP

Table of content: NICOLE RADABAUGH FNP (NPI 1003203316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003203316 NPI number — NICOLE RADABAUGH FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RADABAUGH
Provider First Name:
NICOLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARRISON
Provider Other First Name:
NICOLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003203316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10003 WEBSTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMDEN ON GAULEY
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26208-7713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-226-5725
Provider Business Mailing Address Fax Number:
304-226-3274

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 MINUTEMAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26452-2200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-999-7870
Provider Business Practice Location Address Fax Number:
304-269-0165
Provider Enumeration Date:
04/24/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  APRN59918-NP-C , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810029176 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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