Provider Demographics
NPI:1679210785
Name:OSBORNE, KWANTIA RAYN
Entity Type:Individual
Prefix:
First Name:KWANTIA
Middle Name:RAYN
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MOUNTAIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-8992
Mailing Address - Country:US
Mailing Address - Phone:304-816-3687
Mailing Address - Fax:
Practice Address - Street 1:16 MOUNTAIN PARK DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-8992
Practice Address - Country:US
Practice Address - Phone:304-816-3687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker