Healthcare Provider Details

I. General information

NPI: 1396359014
Provider Name (Legal Business Name): KIMBERLY ANN NULPH-LASECK RTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 MARKET ST
ALBION PA
16401-1131
US

IV. Provider business mailing address

65 MARKET ST
ALBION PA
16401-1131
US

V. Phone/Fax

Practice location:
  • Phone: 814-859-0013
  • Fax:
Mailing address:
  • Phone: 814-859-0013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number254928
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: