Provider Demographics
NPI:1528832276
Name:VERGARA, ARLENE
Entity type:Individual
Prefix:
First Name:ARLENE
Middle Name:
Last Name:VERGARA
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:PO BOX 60
Mailing Address - Street 2:
Mailing Address - City:FAIRPLAY
Mailing Address - State:MD
Mailing Address - Zip Code:21733-0060
Mailing Address - Country:US
Mailing Address - Phone:202-670-7317
Mailing Address - Fax:
Practice Address - Street 1:99 TAVERN RD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2890
Practice Address - Country:US
Practice Address - Phone:304-263-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR199695163WP0808X
WV118367363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health