Basic Information
| Provider Information | |||||||||
| NPI: | 1629361639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | SULLIVAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SULLIVAN | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | GAYLE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 409 S 2ND ST | ||||||||
| Address2: | SUITE 2F | ||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171041612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177823282 | ||||||||
| FaxNumber: | 7172318964 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S FRONT ST | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171012010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177825118 | ||||||||
| FaxNumber: | 7177825854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2011 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN592667 | PA | N | Nursing Service Providers | Registered Nurse | 163W00000X | 174761-30 | WI | N | Nursing Service Providers | Registered Nurse | 367500000X | R162842 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN592667 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 102912432 | 05 | PA | MEDICAID |