Healthcare Provider Details

I. General information

NPI: 1245777960
Provider Name (Legal Business Name): GRETCHEN MCCORD WOLBERT CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2017
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 WOOD ST 256 BECHT HALL
CLARION PA
16214-1240
US

IV. Provider business mailing address

PO BOX 11 411 MAPLE DRIVE
LUCINDA PA
16235-0011
US

V. Phone/Fax

Practice location:
  • Phone: 814-393-2121
  • Fax: 814-393-2035
Mailing address:
  • Phone: 814-226-9091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP016892
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: