Provider Demographics
NPI:1609008416
Name:RICE, LAILAH MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:LAILAH
Middle Name:MARIE
Last Name:RICE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4610 KANAWHA AVE SW STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1367
Mailing Address - Country:US
Mailing Address - Phone:304-205-7992
Mailing Address - Fax:304-205-7739
Practice Address - Street 1:4610 KANAWHA AVE SW STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1367
Practice Address - Country:US
Practice Address - Phone:304-205-7992
Practice Address - Fax:304-205-7739
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant