Provider Demographics
NPI:1770101123
Name:SNYDER, KELLY (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SNYDER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1599 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25387-2514
Mailing Address - Country:US
Mailing Address - Phone:304-344-0586
Mailing Address - Fax:304-344-0586
Practice Address - Street 1:1599 2ND AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25387-2514
Practice Address - Country:US
Practice Address - Phone:304-344-0586
Practice Address - Fax:304-344-0586
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV75668171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1710103676Medicaid