1285858928 NPI number — KRISTIE MARIE ANZULAVICH CRNP

Table of content: KRISTIE MARIE ANZULAVICH CRNP (NPI 1285858928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285858928 NPI number — KRISTIE MARIE ANZULAVICH CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANZULAVICH
Provider First Name:
KRISTIE
Provider Middle Name:
MARIE
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:
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:
1285858928
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 ELM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATSONTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17777-1407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-538-4381
Provider Business Mailing Address Fax Number:
570-538-4381

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
LEWISBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17837-9362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-522-4279
Provider Business Practice Location Address Fax Number:
570-522-2193
Provider Enumeration Date:
04/12/2007

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:  SP009132 , 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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