Provider Demographics
NPI:1427348846
Name:FRUIT, CELICIA NACHELLE
Entity type:Individual
Prefix:MISS
First Name:CELICIA
Middle Name:NACHELLE
Last Name:FRUIT
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 1:204 OAKMONT WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOPE
Mailing Address - State:WV
Mailing Address - Zip Code:25880-9492
Mailing Address - Country:US
Mailing Address - Phone:304-640-2917
Mailing Address - Fax:
Practice Address - Street 1:204 OAKMONT WAY
Practice Address - Street 2:
Practice Address - City:MOUNT HOPE
Practice Address - State:WV
Practice Address - Zip Code:25880-9492
Practice Address - Country:US
Practice Address - Phone:304-640-2917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA01844174400000X
WVC1787174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist