Provider Demographics
NPI:1457917064
Name:SAVAGE, DIETRA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DIETRA
Middle Name:
Last Name:SAVAGE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 PROFESSIONAL PL STE 102103
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-0258
Mailing Address - Country:US
Mailing Address - Phone:304-848-5770
Mailing Address - Fax:304-848-0890
Practice Address - Street 1:65 PROFESSIONAL PL STE 102103
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-0258
Practice Address - Country:US
Practice Address - Phone:304-848-5770
Practice Address - Fax:304-848-0890
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV78228363LF0000X
WV103875363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV78228OtherRN LICENSE