Provider Demographics
NPI:1508820093
Name:DONOVAN, CAROLYN (CCNS, NP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:CCNS, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0897
Mailing Address - Country:US
Mailing Address - Phone:304-293-7401
Mailing Address - Fax:304-293-6963
Practice Address - Street 1:31 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:HARPERS FERRY
Practice Address - State:WV
Practice Address - Zip Code:25425-9519
Practice Address - Country:US
Practice Address - Phone:304-535-6343
Practice Address - Fax:304-293-6963
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23136363L00000X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Not Answered364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7102290000Medicaid
S93093Medicare UPIN
WVDO6029722Medicare ID - Type Unspecified