Provider Demographics
NPI:1366127581
Name:FRESHWATER, BERNELL
Entity type:Individual
Prefix:
First Name:BERNELL
Middle Name:
Last Name:FRESHWATER
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 1:117 COLUMBUS WAY
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-2022
Mailing Address - Country:US
Mailing Address - Phone:304-914-3084
Mailing Address - Fax:
Practice Address - Street 1:117 COLUMBUS WAY
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-2022
Practice Address - Country:US
Practice Address - Phone:304-914-3084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker