1518246669 NPI number — DR. STEPHANIE G KING CRNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518246669 NPI number — DR. STEPHANIE G KING CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KING
Provider First Name:
STEPHANIE
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
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:
BIDWELL
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
G
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:
1518246669
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
307 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18810-1710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-888-1541
Provider Business Mailing Address Fax Number:
570-888-2380

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
307 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18810-1710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-888-1541
Provider Business Practice Location Address Fax Number:
570-888-2380
Provider Enumeration Date:
08/08/2011

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: 363L00000X , with the licence number:  SP011532 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: SP011532 , 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: 1026337300001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2664595 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 828418 . This is a "FIRST PRIORITY HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 9611934 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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