Basic Information
| Provider Information | |||||||||
| NPI: | 1760833966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTLEY | ||||||||
| FirstName: | MICA | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | APRN, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 MORRIS ST | ||||||||
| Address2: | SUITE 357 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043883574 | ||||||||
| FaxNumber: | 3043886481 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 MORRIS ST | ||||||||
| Address2: | SUITE 357 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043883574 | ||||||||
| FaxNumber: | 3043886481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2016 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN73471-NP-C | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.