Provider Demographics
NPI:1619581519
Name:VANOVER, DUSTON RAYE
Entity Type:Individual
Prefix:
First Name:DUSTON
Middle Name:RAYE
Last Name:VANOVER
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 1:415 WILLOW ST APT 3
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-3455
Mailing Address - Country:US
Mailing Address - Phone:304-962-0584
Mailing Address - Fax:
Practice Address - Street 1:415 WILLOW ST APT 3
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3455
Practice Address - Country:US
Practice Address - Phone:304-962-0584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant