Provider Demographics
NPI:1023094729
Name:MOONEY, DEBRA RUSSELL (C-FNP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:RUSSELL
Last Name:MOONEY
Suffix:
Gender:F
Credentials:C-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 SUMMIT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-8847
Mailing Address - Country:US
Mailing Address - Phone:304-756-5715
Mailing Address - Fax:
Practice Address - Street 1:103 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-2314
Practice Address - Country:US
Practice Address - Phone:304-756-5715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV266022084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0116688000Medicaid
R35254Medicare UPIN
WV0116688000Medicaid