Basic Information
| Provider Information | |||||||||
| NPI: | 1740675180 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAGNELL | ||||||||
| FirstName: | MEGHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5 CHEROKEE DR | ||||||||
| Address2: | |||||||||
| City: | MOUNDSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260411009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7248252672 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 37930 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | WOODSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437939247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404721678 | ||||||||
| FaxNumber: | 7404721707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2015 | ||||||||
| LastUpdateDate: | 04/02/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 09885 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.