Provider Demographics
NPI:1891108502
Name:CARPENTER, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:CARPENTER
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 1:4202 MACCORKLE AVE SW STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1513
Mailing Address - Country:US
Mailing Address - Phone:304-925-7546
Mailing Address - Fax:681-205-8369
Practice Address - Street 1:4202 MACCORKLE AVE SW STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1513
Practice Address - Country:US
Practice Address - Phone:304-925-7546
Practice Address - Fax:681-205-8369
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1119180363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical