1548372774 NPI number — WYOMING VALLEY WEST

Table of content: KIMBERLY MARIE WHEATCRAFT PHARMD (NPI 1003284613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548372774 NPI number — WYOMING VALLEY WEST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYOMING VALLEY WEST
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1548372774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 N MAPLE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18704-3630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-288-6551
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 N MAPLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18704-3630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-288-6551
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAYERS
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF SPECIAL EDUCATION
Authorized Official Telephone Number:
570-288-6551

Provider Taxonomy Codes

  • Taxonomy code: 251300000X , 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: 0013059750001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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