Provider Demographics
NPI:1710769328
Name:LIDDON, MAGDELINE (PRSS)
Entity type:Individual
Prefix:
First Name:MAGDELINE
Middle Name:
Last Name:LIDDON
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1448 10TH AVENUE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3579
Mailing Address - Country:US
Mailing Address - Phone:304-691-6381
Mailing Address - Fax:304-691-8591
Practice Address - Street 1:1600 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3656
Practice Address - Country:US
Practice Address - Phone:304-696-8700
Practice Address - Fax:304-696-8701
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21-9132175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist