Provider Demographics
NPI:1417147091
Name:WIMER, MARY ELLEN (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:WIMER
Suffix:
Gender:F
Credentials:NP
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 100
Mailing Address - Street 2:314 PINE STREET
Mailing Address - City:FRANKLIN
Mailing Address - State:WV
Mailing Address - Zip Code:26807-0100
Mailing Address - Country:US
Mailing Address - Phone:304-358-2355
Mailing Address - Fax:304-358-3054
Practice Address - Street 1:314 PINE STREET
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WV
Practice Address - Zip Code:26807-0100
Practice Address - Country:US
Practice Address - Phone:304-358-2355
Practice Address - Fax:304-358-3054
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV39542363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009958Medicaid
WV002000637OtherMS BCBS
WV002000637OtherMS BCBS
WV2029184Medicare PIN