Provider Demographics
NPI:1043922073
Name:HAIRSTON, MARCELLA
Entity type:Individual
Prefix:
First Name:MARCELLA
Middle Name:
Last Name:HAIRSTON
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 1:1614 S KANAWHA ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-6239
Mailing Address - Country:US
Mailing Address - Phone:304-255-1397
Mailing Address - Fax:
Practice Address - Street 1:108 SAUNDERS AVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6239
Practice Address - Country:US
Practice Address - Phone:304-255-1397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1083826038Medicaid
WV1619185147Medicaid