Provider Demographics
NPI:1043566474
Name:STREET, CASEY M (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:M
Last Name:STREET
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:PINE GROVE
Mailing Address - State:WV
Mailing Address - Zip Code:26419-0418
Mailing Address - Country:US
Mailing Address - Phone:304-889-3344
Mailing Address - Fax:
Practice Address - Street 1:RT 20
Practice Address - Street 2:
Practice Address - City:PINE GROVE
Practice Address - State:WV
Practice Address - Zip Code:26419-0418
Practice Address - Country:US
Practice Address - Phone:304-889-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV73105363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily