Provider Demographics
NPI:1790388189
Name:PANNELL, MAKESHA
Entity Type:Individual
Prefix:
First Name:MAKESHA
Middle Name:
Last Name:PANNELL
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 1:612 VIRGINIA ST E STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2175
Mailing Address - Country:US
Mailing Address - Phone:304-343-1130
Mailing Address - Fax:304-343-8944
Practice Address - Street 1:100 WASHINGTON ST E APT 308
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1526
Practice Address - Country:US
Practice Address - Phone:681-265-3618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant