Provider Demographics
NPI:1215033386
Name:RUNYAN, AMY KRISTEN (MPT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KRISTEN
Last Name:RUNYAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:KRISTEN
Other - Last Name:STEELE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 MORRIS ST STE 304
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1853
Mailing Address - Country:US
Mailing Address - Phone:304-388-7783
Mailing Address - Fax:
Practice Address - Street 1:130 GOFF MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1419
Practice Address - Country:US
Practice Address - Phone:304-388-7055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2509225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006516Medicaid
ST4193401Medicare PIN
ST4193402Medicare PIN