Basic Information
| Provider Information | |||||||||
| NPI: | 1902860158 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FABRY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 3500 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911300 | ||||||||
| FaxNumber: | 3046911330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 3500 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911300 | ||||||||
| FaxNumber: | 3046911330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 09/26/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 27383 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7102194000 | 05 | WV | MEDICAID | 2308363 | 05 | OH | MEDICAID | 78009610 | 05 | KY | MEDICAID |