1700217890 NPI number — DR. KAITLYN MELISSA CONNORS

Table of content: DR. KAITLYN MELISSA CONNORS (NPI 1700217890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700217890 NPI number — DR. KAITLYN MELISSA CONNORS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNORS
Provider First Name:
KAITLYN
Provider Middle Name:
MELISSA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1700217890
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 WALNUTWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILKES BARRE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18702-7244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-262-8869
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 MUNDY ST
Provider Second Line Business Practice Location Address:
MAC IV BUILDING
Provider Business Practice Location Address City Name:
WILKES BARRE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18702-6830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-824-0930
Provider Business Practice Location Address Fax Number:
570-824-7755
Provider Enumeration Date:
11/27/2013

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: 111N00000X , with the licence number:  DC010811 , 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: 4177518 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 003013331 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1700217890 . This is a "VIBRA HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1700217890 . This is a "GHP FAMILY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50153952 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 102895430-0002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008246 . This is a "OPTUM" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 25-1645055 . This is a "HUMANA/CHOICE CARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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