1700174687 NPI number — JENNIFER MARIE PFENDER CRNA

Table of content: JENNIFER MARIE PFENDER CRNA (NPI 1700174687)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700174687 NPI number — JENNIFER MARIE PFENDER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PFENDER
Provider First Name:
JENNIFER
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1700174687
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3004 LAKEMONT DR
Provider Second Line Business Mailing Address:
FORBES TOWER SUITE 9055
Provider Business Mailing Address City Name:
CANONSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15317-6220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-916-4975
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 LORTHROP STREET
Provider Second Line Business Practice Location Address:
FORBES TOWER SUITE 9055
Provider Business Practice Location Address City Name:
PITTSBURGH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-647-3087
Provider Business Practice Location Address Fax Number:
412-647-4486
Provider Enumeration Date:
07/13/2011

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: 367500000X , with the licence number:  RN557146 , 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)

  • Identifier: 105063700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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