Provider Demographics
NPI:1225752637
Name:STAFFORD, TIMOTHY DEAN
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DEAN
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:
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 141
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24991-0141
Mailing Address - Country:US
Mailing Address - Phone:304-667-6678
Mailing Address - Fax:
Practice Address - Street 1:9344 SHOESTRING TRL
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:WV
Practice Address - Zip Code:24991-0141
Practice Address - Country:US
Practice Address - Phone:304-661-2336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVEMP47383747P1801X
376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant