Basic Information
| Provider Information | |||||||||
| NPI: | 1588335889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIGHT | ||||||||
| FirstName: | KHRISTINA | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 WILLOWOOD CIR | ||||||||
| Address2: | |||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255269268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042374036 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3415 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043888380 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2021 | ||||||||
| LastUpdateDate: | 09/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 109965 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.