Basic Information
Provider Information | |||||||||
NPI: | 1700257565 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KRATZER | ||||||||
FirstName: | SHELLIE | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DIMM | ||||||||
OtherFirstName: | SHELLIE | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7 DOCK HILL RD | ||||||||
Address2: |   | ||||||||
City: | MIDDLEBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 178428910 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5708372123 | ||||||||
FaxNumber: | 5708372185 | ||||||||
Practice Location | |||||||||
Address1: | 2813 INDUSTRIAL PARK RD | ||||||||
Address2: |   | ||||||||
City: | MIFFLINTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 170599078 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7174368283 | ||||||||
FaxNumber: | 7174368351 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2015 | ||||||||
LastUpdateDate: | 04/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN627395 | PA | N |   | Nursing Service Providers | Registered Nurse |   | 363L00000X | 024625 | PA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | SP015565 | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 1031720750001 | 05 | PA |   | MEDICAID | 462444F6K | 01 | PA | MEDICARE | OTHER |