Provider Demographics
NPI:1093284937
Name:PHOENIX RISING HEALTHCARE
Entity Type:Organization
Organization Name:PHOENIX RISING HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER OF LLC
Authorized Official - Prefix:MISS
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNEHILL
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:304-366-0111
Mailing Address - Street 1:PO BOX 1286
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26555-1286
Mailing Address - Country:US
Mailing Address - Phone:304-366-0111
Mailing Address - Fax:304-366-2099
Practice Address - Street 1:5 ERWIN LN STE A
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1376
Practice Address - Country:US
Practice Address - Phone:304-366-0111
Practice Address - Fax:304-366-2099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-21
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty