Basic Information
| Provider Information | |||||||||
| NPI: | 1508820093 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DONOVAN | ||||||||
| FirstName: | CAROLYN | ||||||||
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| Credential: | CCNS, NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 897 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265070897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042937401 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | HARPERS FERRY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254259519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045356343 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 23136 | WV | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364SP0808X | 23136 | WV | X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7102290000 | 05 | WV | MEDICAID |