Basic Information
| Provider Information | |||||||||
| NPI: | 1386065910 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANLEY | ||||||||
| FirstName: | JAMIE | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 ROCKLAND RD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198033607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026514200 | ||||||||
| FaxNumber: | 3026515345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2013 | ||||||||
| LastUpdateDate: | 04/25/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | LJ-0000310 | DE | Y | Allopathic & Osteopathic Physicians | Pediatrics | 363L00000X | L1-0041332 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1136569-00 | 05 | MD | MEDICAID | 0539457 | 05 | NJ | MEDICAID |