Provider Demographics
NPI:1609480649
Name:WEASENFORTH, STEPHEN ROY
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ROY
Last Name:WEASENFORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 E EAGLE LN
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-9527
Mailing Address - Country:US
Mailing Address - Phone:304-788-3626
Mailing Address - Fax:
Practice Address - Street 1:144 E EAGLE LN
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-9527
Practice Address - Country:US
Practice Address - Phone:304-788-3626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant