1053449504 NPI number — MS. JIAJOYCE RENEE RICHARDSON CRNP

Table of content: MS. JIAJOYCE RENEE RICHARDSON CRNP (NPI 1053449504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053449504 NPI number — MS. JIAJOYCE RENEE RICHARDSON CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICHARDSON
Provider First Name:
JIAJOYCE
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CONWAY
Provider Other First Name:
JIAJOYCE
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053449504
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4518 UNION DEPOSIT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRISBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17111-2921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-526-1030
Provider Business Mailing Address Fax Number:
717-741-9605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4518 UNION DEPOSIT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARRISBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17111-2921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-526-1030
Provider Business Practice Location Address Fax Number:
717-741-9605
Provider Enumeration Date:
02/28/2007

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: 363LF0000X , with the licence number:  SP009284 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: R149858 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 102130992-0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50078124 . This is a "BLUE CROSS INDIVIDUAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 125050E7M . This is a "MEDICARE IND" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 893477-01 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 4123778-00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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