Provider Demographics
NPI:1366111825
Name:CARNELL, CLARISSA (PTA)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
Last Name:CARNELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10790 FORT ASHBY RD
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-6229
Mailing Address - Country:US
Mailing Address - Phone:304-813-6597
Mailing Address - Fax:
Practice Address - Street 1:260 SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:ROMNEY
Practice Address - State:WV
Practice Address - Zip Code:26757-6345
Practice Address - Country:US
Practice Address - Phone:304-822-7527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002760225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV002760OtherPHYSICAL THERAPIST ASSISTANT