Provider Demographics
NPI:1376944637
Name:MOONEY, SARA ASHLEY (FNP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:ASHLEY
Last Name:MOONEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:A
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1393 HAWVER RD
Mailing Address - Street 2:
Mailing Address - City:HICO
Mailing Address - State:WV
Mailing Address - Zip Code:25854-7365
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1606 KANAWHA BLVD W
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25387-2536
Practice Address - Country:US
Practice Address - Phone:304-768-8523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVF0914132363L00000X
WV74101363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0011253000OtherMEDICAID GROUP
WVP01537998OtherRAILROAD MEDICARE
WV3093125OtherHIGHMARK
WV3810028077Medicaid
WV9296571OtherMEDICARE GROUP PIN
WV3810028077Medicaid