Provider Demographics
NPI:1790979300
Name:SIZEMORE, MARY ELLEN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:SIZEMORE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 WHITTINGTON PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4930
Mailing Address - Country:US
Mailing Address - Phone:502-327-9100
Mailing Address - Fax:855-632-8329
Practice Address - Street 1:3501 MACCORKLE AVE SE
Practice Address - Street 2:SE#151
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1419
Practice Address - Country:US
Practice Address - Phone:304-964-6370
Practice Address - Fax:855-632-8329
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV52805363LF0000X, 363L00000X
WVAPRN52805-FNP-BC363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810010313Medicaid
WV3810010313Medicaid
WV2029565Medicare PIN
WV2029564Medicare PIN
WV2029562Medicare PIN
WV2029563Medicare PIN