1457345035 NPI number — MRS. JOAN ELYSE BACKENSTOE CRNA

Table of content: MRS. JOAN ELYSE BACKENSTOE CRNA (NPI 1457345035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457345035 NPI number — MRS. JOAN ELYSE BACKENSTOE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BACKENSTOE
Provider First Name:
JOAN
Provider Middle Name:
ELYSE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457345035
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4653 STEVEN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALNUTPORT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18088-9619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-767-3476
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3147 COLLEGE HEIGHTS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALLENTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18104-4813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-841-2432
Provider Business Practice Location Address Fax Number:
610-841-4433
Provider Enumeration Date:
09/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  RN184932L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00456743 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1466649 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 20035314 . This is a "AMERIHEALTH MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0016767680004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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