Provider Demographics
NPI:1265029599
Name:CARR, ELECIA
Entity type:Individual
Prefix:
First Name:ELECIA
Middle Name:
Last Name:CARR
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 1:491 SWAN POND RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404-0410
Mailing Address - Country:US
Mailing Address - Phone:304-820-2801
Mailing Address - Fax:
Practice Address - Street 1:214 JOSHUA DR APT 609
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404-4200
Practice Address - Country:US
Practice Address - Phone:304-240-1093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV00100764038Medicaid