Provider Demographics
NPI:1992429484
Name:WRISTON, LYNDSIE RAE (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:LYNDSIE
Middle Name:RAE
Last Name:WRISTON
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:LYNDSIE
Other - Middle Name:RAE
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 CLEARVIEW LN
Mailing Address - Street 2:
Mailing Address - City:WALLBACK
Mailing Address - State:WV
Mailing Address - Zip Code:25285-9273
Mailing Address - Country:US
Mailing Address - Phone:304-880-6232
Mailing Address - Fax:
Practice Address - Street 1:3100 MACCORKLE AVE SE STE 411
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1230
Practice Address - Country:US
Practice Address - Phone:304-343-4400
Practice Address - Fax:304-345-5005
Is Sole Proprietor?:No
Enumeration Date:2022-09-28
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV114078363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1992429484Medicaid