Provider Demographics
NPI:1154188597
Name:WEISENBORN, KELLY ANNE (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:WEISENBORN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 HOPEWELL RD
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-5496
Mailing Address - Country:US
Mailing Address - Phone:304-677-5262
Mailing Address - Fax:
Practice Address - Street 1:900 VIRGINIA ST E STE 400
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2835
Practice Address - Country:US
Practice Address - Phone:681-313-4759
Practice Address - Fax:844-800-3954
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV83736163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse