Provider Demographics
NPI:1780964296
Name:KIRK, NANCY LAUREN (MOT)
Entity type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:LAUREN
Last Name:KIRK
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2815
Mailing Address - Country:US
Mailing Address - Phone:304-599-1500
Mailing Address - Fax:304-599-7800
Practice Address - Street 1:1052 MAPLE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2815
Practice Address - Country:US
Practice Address - Phone:304-599-1500
Practice Address - Fax:304-599-7800
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1550225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV516524Medicare Oscar/Certification