1568597839 NPI number — WENDY BLACK DORN CRNP

Table of content: WENDY BLACK DORN CRNP (NPI 1568597839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568597839 NPI number — WENDY BLACK DORN CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK DORN
Provider First Name:
WENDY
Provider Middle Name:
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:
BLACK
Provider Other First Name:
WENDY
Provider Other Middle Name:
SUSANNE
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:
1568597839
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 E LANCASTER AVE
Provider Second Line Business Mailing Address:
MOB EAST, SUITE 561
Provider Business Mailing Address City Name:
WYNNEWOOD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19096-3450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-642-7714
Provider Business Mailing Address Fax Number:
610-649-0761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 OLD YORK RD
Provider Second Line Business Practice Location Address:
GROUND FLOOR TOLL BLDG
Provider Business Practice Location Address City Name:
ABINGTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19001-3720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-481-6784
Provider Business Practice Location Address Fax Number:
215-481-3611
Provider Enumeration Date:
02/23/2007

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: 363LW0102X , with the licence number:  SP009006 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LX0001X , with the licence number: SP009006 , 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)