Basic Information
| Provider Information | |||||||||
| NPI: | 1083807002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEBB | ||||||||
| FirstName: | GAYLEY | ||||||||
| MiddleName: | BLAINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLAINE | ||||||||
| OtherFirstName: | GAYLEY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3400 CIVIC CENTER BLVD | ||||||||
| Address2: | 2ND FL EAST | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191045127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156154949 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3400 CIVIC CENTER BLVD | ||||||||
| Address2: | 2ND FL EAST | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191045127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156154949 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2007 | ||||||||
| LastUpdateDate: | 03/28/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | SP009808 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 103194715 | 05 | PA | MEDICAID |