Basic Information
| Provider Information | |||||||||
| NPI: | 1982223582 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDLEBLUTE | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | HEATHER | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3421 CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2250 E MARKET ST | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174022857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178121566 | ||||||||
| FaxNumber: | 7178123950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2020 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP021789 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163W00000X | RN630278 | PA | N | Nursing Service Providers | Registered Nurse |
No ID Information.