Provider Demographics
NPI:1154000651
Name:STACKPOLE, BETSY NICOLE
Entity type:Individual
Prefix:
First Name:BETSY
Middle Name:NICOLE
Last Name:STACKPOLE
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 1:4124 SHORTLINE HWY
Mailing Address - Street 2:
Mailing Address - City:PORTERS FALLS
Mailing Address - State:WV
Mailing Address - Zip Code:26162-7200
Mailing Address - Country:US
Mailing Address - Phone:304-386-5095
Mailing Address - Fax:
Practice Address - Street 1:4124 SHORTLINE HWY
Practice Address - Street 2:
Practice Address - City:PORTERS FALLS
Practice Address - State:WV
Practice Address - Zip Code:26162-7200
Practice Address - Country:US
Practice Address - Phone:304-386-5095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker