Provider Demographics
NPI:1215219902
Name:GAUTIER, KELLIE FAYE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:FAYE
Last Name:GAUTIER
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 1:330 CEDARCREST DR
Mailing Address - Street 2:
Mailing Address - City:SHADY SPRING
Mailing Address - State:WV
Mailing Address - Zip Code:25918-8541
Mailing Address - Country:US
Mailing Address - Phone:304-890-8987
Mailing Address - Fax:
Practice Address - Street 1:277 GREASY RIDGE RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24739-6900
Practice Address - Country:US
Practice Address - Phone:304-425-7615
Practice Address - Fax:304-425-7635
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV73240363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810021842Medicaid
WV3810021842Medicaid