Provider Demographics
NPI:1235408261
Name:CUNNINGHAM, LOREN N (PAC)
Entity Type:Individual
Prefix:MRS
First Name:LOREN
Middle Name:N
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:LOREN
Other - Middle Name:N
Other - Last Name:GOODALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:111 S GROVE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-1805
Mailing Address - Country:US
Mailing Address - Phone:304-257-2451
Mailing Address - Fax:
Practice Address - Street 1:111 S GROVE ST STE 1
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1805
Practice Address - Country:US
Practice Address - Phone:304-257-2451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01564363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical