Provider Demographics
NPI:1366020166
Name:KEADLE, KATHY
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:KEADLE
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:PO BOX 556
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:WV
Mailing Address - Zip Code:25984-0556
Mailing Address - Country:US
Mailing Address - Phone:304-392-5138
Mailing Address - Fax:
Practice Address - Street 1:284 GREENBRIER STREET
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:WV
Practice Address - Zip Code:25984-2598
Practice Address - Country:US
Practice Address - Phone:304-392-5138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV50672163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health