Basic Information
| Provider Information | |||||||||
| NPI: | 1164088647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | APRN, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 691 | ||||||||
| Address2: | |||||||||
| City: | UNEEDA | ||||||||
| State: | WV | ||||||||
| PostalCode: | 252050691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049281886 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253023351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043885432 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2019 | ||||||||
| LastUpdateDate: | 05/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN61702NP | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.