Provider Demographics
NPI:1528476793
Name:OWENS, KACIE (PPCNP-BC)
Entity type:Individual
Prefix:
First Name:KACIE
Middle Name:
Last Name:OWENS
Suffix:
Gender:F
Credentials:PPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 124
Mailing Address - Street 2:
Mailing Address - City:ELEANOR
Mailing Address - State:WV
Mailing Address - Zip Code:25070-0124
Mailing Address - Country:US
Mailing Address - Phone:304-542-1090
Mailing Address - Fax:
Practice Address - Street 1:830 PENNSLYVANIA AVENUE
Practice Address - Street 2:SUITE 103
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3389
Practice Address - Country:US
Practice Address - Phone:304-388-1552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN78736-CPNP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810028354Medicaid