1336104819 NPI number — MRS. JEANNE M. SHOULDERS CRNP

Table of content: MRS. JEANNE M. SHOULDERS CRNP (NPI 1336104819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336104819 NPI number — MRS. JEANNE M. SHOULDERS CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOULDERS
Provider First Name:
JEANNE
Provider Middle Name:
M.
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:
MCCLURE
Provider Other First Name:
JEANNE
Provider Other Middle Name:
PAUL
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:
1336104819
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 MAPLE ST
Provider Second Line Business Mailing Address:
SUITES ON MAPLE EAST, SUITE G-65
Provider Business Mailing Address City Name:
INDIANA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15705-1074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-357-2550
Provider Business Mailing Address Fax Number:
724-357-6212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1097 OAK STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-349-2022
Provider Business Practice Location Address Fax Number:
724-349-8735
Provider Enumeration Date:
04/19/2006

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:  RN522348L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LW0102X , with the licence number: SP008108 , 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: 1991407 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: MC1584937 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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