1083807002 NPI number — GAYLEY BLAINE WEBB CRNP

Table of content: GAYLEY BLAINE WEBB CRNP (NPI 1083807002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083807002 NPI number — GAYLEY BLAINE WEBB CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEBB
Provider First Name:
GAYLEY
Provider Middle Name:
BLAINE
Provider Name Prefix Text:
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:
BLAINE
Provider Other First Name:
GAYLEY
Provider Other Middle Name:
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:
1083807002
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3400 CIVIC CENTER BLVD
Provider Second Line Business Mailing Address:
2ND FL EAST
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19104-5127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-615-4949
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 CIVIC CENTER BLVD
Provider Second Line Business Practice Location Address:
2ND FL EAST
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-5127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-615-4949
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2007

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: 363LA2200X , with the licence number:  SP009808 , 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: 103194715 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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