Basic Information
Provider Information | |||||||||
NPI: | 1710971213 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WOLVERTON | ||||||||
FirstName: | NANCY | ||||||||
MiddleName: | JEAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 118 12TH STREET | ||||||||
Address2: |   | ||||||||
City: | PRINCETON | ||||||||
State: | WV | ||||||||
PostalCode: | 247402352 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044315153 | ||||||||
FaxNumber: | 3044877835 | ||||||||
Practice Location | |||||||||
Address1: | 1333 SOUTHVIEW DR | ||||||||
Address2: |   | ||||||||
City: | BLUEFIELD | ||||||||
State: | WV | ||||||||
PostalCode: | 247014317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043279205 | ||||||||
FaxNumber: | 3043279210 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2005 | ||||||||
LastUpdateDate: | 08/01/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN1502412 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 305483700 | 05 | FL |   | MEDICAID | Y022R | 01 | FL | BLUE SHIELD PROV # | OTHER |