Provider Demographics
NPI:1497355168
Name:WILEY, TINA LOUISE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LOUISE
Last Name:WILEY
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 518
Mailing Address - Street 2:
Mailing Address - City:VERDUNVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25649-0518
Mailing Address - Country:US
Mailing Address - Phone:304-688-9821
Mailing Address - Fax:
Practice Address - Street 1:412 SMITH STREET
Practice Address - Street 2:
Practice Address - City:VERDUNVILLE
Practice Address - State:WV
Practice Address - Zip Code:25649-2564
Practice Address - Country:US
Practice Address - Phone:304-688-9821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant