Provider Demographics
NPI:1780128439
Name:VERBURG, JOHANNA (DNP)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:VERBURG
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:
Other - Last Name:OVERSTREET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:14 WINE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-2676
Mailing Address - Country:US
Mailing Address - Phone:681-404-0211
Mailing Address - Fax:
Practice Address - Street 1:14 WINE DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2676
Practice Address - Country:US
Practice Address - Phone:681-404-0211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-15
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-144007363LF0000X
WV107770363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty