Provider Demographics
NPI:1710971213
Name:WOLVERTON, NANCY JEAN (ARNP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:JEAN
Last Name:WOLVERTON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 12TH STREET
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2352
Mailing Address - Country:US
Mailing Address - Phone:304-431-5153
Mailing Address - Fax:304-487-7835
Practice Address - Street 1:1333 SOUTHVIEW DR
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-4317
Practice Address - Country:US
Practice Address - Phone:304-327-9205
Practice Address - Fax:304-327-9210
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1502412363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305483700Medicaid
FLY022ROtherBLUE SHIELD PROV #
FL305483700Medicaid
FLY022ROtherBLUE SHIELD PROV #