Provider Demographics
NPI:1114674892
Name:LAFFERTY, RACHEAL NICOLE
Entity Type:Individual
Prefix:
First Name:RACHEAL
Middle Name:NICOLE
Last Name:LAFFERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 HARPER RD STE A&B2ND
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3373
Mailing Address - Country:US
Mailing Address - Phone:304-254-3042
Mailing Address - Fax:304-461-3703
Practice Address - Street 1:1717 HARPER RD STE A&B2ND
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3373
Practice Address - Country:US
Practice Address - Phone:304-254-3042
Practice Address - Fax:304-461-3703
Is Sole Proprietor?:No
Enumeration Date:2022-03-03
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
WV854363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program