Basic Information
| Provider Information | |||||||||
| NPI: | 1811980378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEAVES | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | GAIL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCKINNEY | ||||||||
| OtherFirstName: | CRYSTAL | ||||||||
| OtherMiddleName: | GAIL | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 645 KANAWHA AVE | ||||||||
| Address2: | RAINELLE MEDICAL CENTER | ||||||||
| City: | RAINELLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259621013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044386188 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 645 KANAWHA AVE | ||||||||
| Address2: | RAINELLE MEDICAL CENTER | ||||||||
| City: | RAINELLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259621013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044386188 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 10/19/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 53104 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7103195000 | 05 | WV | MEDICAID |