Provider Demographics
NPI:1407283245
Name:IMAGINE MEDISPA
Entity Type:Organization
Organization Name:IMAGINE MEDISPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:PHARES
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:304-574-6144
Mailing Address - Street 1:127 OAKWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-6648
Mailing Address - Country:US
Mailing Address - Phone:304-574-6144
Mailing Address - Fax:
Practice Address - Street 1:321 DRY HILL RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2601
Practice Address - Country:US
Practice Address - Phone:304-252-4154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN77359-FNP-BC363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherNA