Provider Demographics
NPI:1194103994
Name:MCDANIEL, JEREMY (FNP-BC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2585 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1642
Mailing Address - Country:US
Mailing Address - Phone:304-781-5159
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:3729 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9705
Practice Address - Country:US
Practice Address - Phone:304-760-6042
Practice Address - Fax:304-760-6042
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV64727163WC1500X
WVAPRN64727NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100383130Medicaid
OH0143784Medicaid
WV3810029833Medicaid
WVWV5938Medicare PIN