Provider Demographics
NPI:1588178511
Name:LAI FANG, MARILYN (RN)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:LAI FANG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:JEFFERSON COUNTY BOARD OF EDUCATION
Mailing Address - Street 2:110 MORDINGTON AVENUE
Mailing Address - City:CHARLES TOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25414
Mailing Address - Country:US
Mailing Address - Phone:304-267-3595
Mailing Address - Fax:304-267-3599
Practice Address - Street 1:110 MORDINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-1693
Practice Address - Country:US
Practice Address - Phone:304-267-3595
Practice Address - Fax:304-267-3599
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV60293163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV60293OtherWV BOARD OF EXAMINERS REGISTERED NURSES