Provider Demographics
NPI:1235740200
Name:BECKETT, FONDA
Entity Type:Individual
Prefix:
First Name:FONDA
Middle Name:
Last Name:BECKETT
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 1:279 WRIGHTS LANE
Mailing Address - Street 2:
Mailing Address - City:BORRALO
Mailing Address - State:WV
Mailing Address - Zip Code:25033
Mailing Address - Country:US
Mailing Address - Phone:304-437-1614
Mailing Address - Fax:
Practice Address - Street 1:279 WRIGHTS LANE
Practice Address - Street 2:
Practice Address - City:BORRALO
Practice Address - State:WV
Practice Address - Zip Code:25033
Practice Address - Country:US
Practice Address - Phone:304-437-1614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant