Healthcare Provider Details

I. General information

NPI: 1093544595
Provider Name (Legal Business Name): JEANNIE MARIE WALDRON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1984 ROUTE 22 HWY W
BLAIRSVILLE PA
15717-1264
US

IV. Provider business mailing address

344 N LIBERTY ST
BLAIRSVILLE PA
15717-1322
US

V. Phone/Fax

Practice location:
  • Phone: 724-459-4886
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN-309894
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: