Basic Information
| Provider Information | |||||||||
| NPI: | 1245778232 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LISTERMANN | ||||||||
| FirstName: | ERIN | ||||||||
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| Credential: | RN, CNM, APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 97 GREAT TEAYS BLVD | ||||||||
| Address2: | STE 6 | ||||||||
| City: | SCOTT DEPOT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255609815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047576999 | ||||||||
| FaxNumber: | 3042015019 | ||||||||
| Practice Location | |||||||||
| Address1: | 97 GREAT TEAYS BLVD | ||||||||
| Address2: | STE 6 | ||||||||
| City: | SCOTT DEPOT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255609815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047576999 | ||||||||
| FaxNumber: | 3042015019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2017 | ||||||||
| LastUpdateDate: | 08/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 78395 | WV | N | Nursing Service Providers | Registered Nurse | 367A00000X | APRN78395MIDWIFE | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 1245778232 | 05 | WV | MEDICAID |