Provider Demographics
NPI:1144830761
Name:PACK, EMILY ROSE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ROSE
Last Name:PACK
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 1:208 AMETHYST DRIVE
Mailing Address - Street 2:
Mailing Address - City:DAVIN
Mailing Address - State:WV
Mailing Address - Zip Code:25617
Mailing Address - Country:US
Mailing Address - Phone:304-583-5189
Mailing Address - Fax:
Practice Address - Street 1:208 AMETHYST DRIVE
Practice Address - Street 2:
Practice Address - City:DAVIN
Practice Address - State:WV
Practice Address - Zip Code:25617
Practice Address - Country:US
Practice Address - Phone:304-583-5189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant