Provider Demographics
NPI:1568063402
Name:MINIMAH-BEANE, JOVON
Entity Type:Individual
Prefix:
First Name:JOVON
Middle Name:
Last Name:MINIMAH-BEANE
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 1:612 VIRGINIA ST E STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2175
Mailing Address - Country:US
Mailing Address - Phone:304-343-1130
Mailing Address - Fax:304-343-8944
Practice Address - Street 1:612 VIRGINIA ST E STE 300
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2175
Practice Address - Country:US
Practice Address - Phone:304-343-1130
Practice Address - Fax:304-343-8944
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0030979001Medicaid