1922336452 NPI number — MS. JENICE DIANE PALACHICK CRNP

Table of content: MS. JENICE DIANE PALACHICK CRNP (NPI 1922336452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922336452 NPI number — MS. JENICE DIANE PALACHICK CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PALACHICK
Provider First Name:
JENICE
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MS.
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:
PALACHICK FRANK
Provider Other First Name:
JENICE
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922336452
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
213 S JEFFERSON ST STE 1006
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24011-1713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-224-5352
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4035 ELECTRIC RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24018-8449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-772-8670
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2009

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:  0024185916 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: SP010477 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: SP010477 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 541024000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 25-1716306 . This is a "HEALTHNET/TRICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 25-1716306 . This is a "INTERGROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00802876 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 25-1716306 . This is a "DEVON" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50090234 . This is a "CAPITAL BLUECROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 679M . This is a "MEDICARE GROUP #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 25-1716306 . This is a "MULTIPLAN/PHCS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 867633 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007307260034 . This is a "MEDICAID GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 102416560 0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: SP010477 . This is a "LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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