Provider Demographics
NPI:1619286796
Name:METZ, STEPHANIE DAWN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DAWN
Last Name:METZ
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4619 KANAWHA AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1319
Mailing Address - Country:US
Mailing Address - Phone:304-400-4545
Mailing Address - Fax:304-400-4546
Practice Address - Street 1:503 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:ELEANOR
Practice Address - State:WV
Practice Address - Zip Code:25070-1390
Practice Address - Country:US
Practice Address - Phone:304-586-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV56366363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1619286796Medicaid