1609823087 NPI number — MS. STEPHANIE FLEETWOOD DEIVERT R.D.

Table of content: MS. STEPHANIE FLEETWOOD DEIVERT R.D. (NPI 1609823087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609823087 NPI number — MS. STEPHANIE FLEETWOOD DEIVERT R.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEIVERT
Provider First Name:
STEPHANIE
Provider Middle Name:
FLEETWOOD
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
R.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YEAGER
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
FLEETWOOD
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609823087
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 N ACADEMY AVE
Provider Second Line Business Mailing Address:
CREDENTIALS DEPT
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17822-4903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-271-6144
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
521 MT PLEASANT DR
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:
18503-1993
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-342-8500
Provider Business Practice Location Address Fax Number:
570-558-2290
Provider Enumeration Date:
05/30/2006

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:  DN003387 , 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)





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