Basic Information
| Provider Information | |||||||||
| NPI: | 1295360501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | KAITLIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 608 NEW HOPE RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044251522 | ||||||||
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| Practice Location | |||||||||
| Address1: | 122 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044877000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2020 | ||||||||
| LastUpdateDate: | 03/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 105447 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.