Provider Demographics
NPI:1104623172
Name:CUNNINGHAM, WANETA K (PRSS)
Entity type:Individual
Prefix:
First Name:WANETA
Middle Name:K
Last Name:CUNNINGHAM
Suffix:
Gender:
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 EVERETTE BAILEY RD
Mailing Address - Street 2:
Mailing Address - City:MATOAKA
Mailing Address - State:WV
Mailing Address - Zip Code:24736-7210
Mailing Address - Country:US
Mailing Address - Phone:681-489-5229
Mailing Address - Fax:
Practice Address - Street 1:106 THORN ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-3560
Practice Address - Country:US
Practice Address - Phone:304-314-7501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24-9119175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist