Provider Demographics
NPI:1790726024
Name:MALONE, BEVERLY JEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:JEAN
Last Name:MALONE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 414
Mailing Address - Street 2:
Mailing Address - City:DELLSLOW
Mailing Address - State:WV
Mailing Address - Zip Code:26531-0414
Mailing Address - Country:US
Mailing Address - Phone:304-290-9424
Mailing Address - Fax:
Practice Address - Street 1:1200 J D ANDERSON DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3494
Practice Address - Country:US
Practice Address - Phone:706-650-0705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26866367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001706470OtherMSBCBS GROUP
WVP00195729OtherRR MEDICARE
WV0207026000Medicaid
WV0068107000Medicaid
MD4061268OtherMARYLAND MEDICAID
WVDA0096OtherRR MEDICARE
WVDA0096OtherRR MEDICARE
WV8217234Medicare PIN
WV001706470OtherMSBCBS GROUP
WV9333201Medicare PIN
WV27005299701OtherBRICKSTREET
WV270052997004OtherTRICARE
WVDA0096OtherRR MEDICARE
WV27005299700OtherWORKERS COMP
WV27005299701OtherWORKERS COMP