1689060477 NPI number — MRS. KIMBERLY PEZZOTTI DEWIRE CRNP

Table of content: MRS. KIMBERLY PEZZOTTI DEWIRE CRNP (NPI 1689060477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689060477 NPI number — MRS. KIMBERLY PEZZOTTI DEWIRE CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEWIRE
Provider First Name:
KIMBERLY
Provider Middle Name:
PEZZOTTI
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:
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:
1689060477
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
649 N LEWIS RD
Provider Second Line Business Mailing Address:
STE 130
Provider Business Mailing Address City Name:
ROYERSFORD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19468-1234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-495-8101
Provider Business Mailing Address Fax Number:
610-495-8106

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
649 N LEWIS RD
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
ROYERSFORD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19468-1234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-495-8101
Provider Business Practice Location Address Fax Number:
610-495-8106
Provider Enumeration Date:
04/08/2015

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: 363LF0000X , with the licence number:  SP014948 , 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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