1215274659 NPI number — LAURIE ELLEN WASKOVICH M.S., R.D., LDN

Table of content: LAURIE ELLEN WASKOVICH M.S., R.D., LDN (NPI 1215274659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215274659 NPI number — LAURIE ELLEN WASKOVICH M.S., R.D., LDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WASKOVICH
Provider First Name:
LAURIE
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., R.D., LDN
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:
1215274659
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 PUBLIC SQ
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
WILKES BARRE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18701-1702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-826-1777
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 MADISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCRANTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18510-1631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-961-5550
Provider Business Practice Location Address Fax Number:
570-961-3844
Provider Enumeration Date:
01/04/2013

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: 133V00000X , with the licence number:  DN000965 , 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: 1027974660003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1007678420044 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1027974660002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1027974660004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1007678420041 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1007678420042 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1007678420040 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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