1295766046 NPI number — MARIE SUSAN GAETANO CRNP

Table of content: MARIE SUSAN GAETANO CRNP (NPI 1295766046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295766046 NPI number — MARIE SUSAN GAETANO CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAETANO
Provider First Name:
MARIE
Provider Middle Name:
SUSAN
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:
WALSH
Provider Other First Name:
MARIE
Provider Other Middle Name:
SUSAN
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:
1295766046
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 WALNUT ST
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
LEMOYNE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17043-1168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-761-0208
Provider Business Mailing Address Fax Number:
717-761-2023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4470 VALLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENOLA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17025-1443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-732-8883
Provider Business Practice Location Address Fax Number:
717-732-1640
Provider Enumeration Date:
07/06/2006

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: 363LF0000X , with the licence number:  SP008299 , 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)