Provider Demographics
NPI:1235989195
Name:MCDOUGAL, KRISTIE SAMANTHA
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:SAMANTHA
Last Name:MCDOUGAL
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 1:2443 VETERANS HWY
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-7474
Mailing Address - Country:US
Mailing Address - Phone:304-771-1174
Mailing Address - Fax:
Practice Address - Street 1:2443 VETERANS HWY
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-7474
Practice Address - Country:US
Practice Address - Phone:304-771-1174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1821206228Medicaid
WV125553494Medicaid
WV1356607394Medicaid