Provider Demographics
NPI:1780292979
Name:WILLS, NICHOLE DAWN
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:DAWN
Last Name:WILLS
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:PO BOX 552
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:WV
Mailing Address - Zip Code:25813-0552
Mailing Address - Country:US
Mailing Address - Phone:304-673-1193
Mailing Address - Fax:304-254-8526
Practice Address - Street 1:1097 GREENBAG RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-1532
Practice Address - Country:US
Practice Address - Phone:304-291-9066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant