Healthcare Provider Details

I. General information

NPI: 1477532653
Provider Name (Legal Business Name): ANNVILLE FAMILY MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 12/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 N WEABER ST
ANNVILLE PA
17003-1104
US

IV. Provider business mailing address

475 N WEABER ST
ANNVILLE PA
17003-1104
US

V. Phone/Fax

Practice location:
  • Phone: 717-867-4671
  • Fax:
Mailing address:
  • Phone: 717-867-4671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: VELMA A NICKLISS
Title or Position: OFFICE MANAGER
Credential:
Phone: 717-867-4671