1114256138 NPI number — MRS. FAWN LYNN BALDAUF CRNP

Table of content: MRS. FAWN LYNN BALDAUF CRNP (NPI 1114256138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114256138 NPI number — MRS. FAWN LYNN BALDAUF CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALDAUF
Provider First Name:
FAWN
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
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:
TETER
Provider Other First Name:
FAWN
Provider Other Middle Name:
LYNN
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:
1114256138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
795 BALDAUF RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYRONE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16686-6260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-778-4239
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
502 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEARFIELD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16830-2100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-765-2950
Provider Business Practice Location Address Fax Number:
814-765-0173
Provider Enumeration Date:
12/22/2009

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: 163W00000X , with the licence number:  RN581431 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: SP016692 , 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)