Provider Demographics
NPI:1518566165
Name:FUSTON, MCKENNA ELISE
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:ELISE
Last Name:FUSTON
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 1:248 BASIL LN
Mailing Address - Street 2:
Mailing Address - City:GERRARDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25420-4295
Mailing Address - Country:US
Mailing Address - Phone:304-283-9212
Mailing Address - Fax:
Practice Address - Street 1:248 BASIL LN
Practice Address - Street 2:
Practice Address - City:GERRARDSTOWN
Practice Address - State:WV
Practice Address - Zip Code:25420-4295
Practice Address - Country:US
Practice Address - Phone:304-283-9212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant