1790877611 NPI number — JULIE DORSEY BOERSEN RN FNP-BC

Table of content: JULIE DORSEY BOERSEN RN FNP-BC (NPI 1790877611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790877611 NPI number — JULIE DORSEY BOERSEN RN FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOERSEN
Provider First Name:
JULIE
Provider Middle Name:
DORSEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN FNP-BC
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:
1790877611
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 GUTHRIE SQ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAYRE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18840-1625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-888-5858
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3344 CHAMBERS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HORSEHEADS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14845-1403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-333-3191
Provider Business Practice Location Address Fax Number:
570-887-6822
Provider Enumeration Date:
09/28/2006

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: 363L00000X , with the licence number:  F332105-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: NYF332105 1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02277452 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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