Individual
NICOLE WILEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
401 DIVISION ST, SUITE 205, SOUTH CHARLESTON, WV 25309
(304) 414-4875
(304) 414-4876
Mailing address
1430 NOTTINGHAM RD, CHARLESTON, WV 25314-2434
(304) 541-7177
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
2204
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3810008840
GROUP MEDICAID
WV
05
—
3811012117
—
WV
01
—
B441
MEDICARE GROUP NUMBER
WV
Enumeration date
04/17/2007
Last updated
06/27/2018
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