Provider Demographics
NPI:1982400909
Name:STONEBURNER, IDA MAE
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:MAE
Last Name:STONEBURNER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:RANSON
Mailing Address - State:WV
Mailing Address - Zip Code:25438-1405
Mailing Address - Country:US
Mailing Address - Phone:304-725-4044
Mailing Address - Fax:
Practice Address - Street 1:103 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1405
Practice Address - Country:US
Practice Address - Phone:304-725-4044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant