Provider Demographics
NPI:1477294692
Name:ANKROM, PAYNE WESTLEY
Entity Type:Individual
Prefix:
First Name:PAYNE
Middle Name:WESTLEY
Last Name:ANKROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WILLOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26104-1003
Mailing Address - Country:US
Mailing Address - Phone:304-482-7528
Mailing Address - Fax:
Practice Address - Street 1:2323 MURDOCH AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-2532
Practice Address - Country:US
Practice Address - Phone:304-422-2884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-03
Last Update Date:2022-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV180Medicaid