Healthcare Provider Details

I. General information

NPI: 1750817904
Provider Name (Legal Business Name): CAROL WEILACHER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL MAIONE

II. Dates (important events)

Enumeration Date: 05/10/2017
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 YORK ST
CORRY PA
16407-1412
US

IV. Provider business mailing address

315 YORK ST
CORRY PA
16407-1412
US

V. Phone/Fax

Practice location:
  • Phone: 814-664-8686
  • Fax: 814-664-9826
Mailing address:
  • Phone: 814-664-8886
  • Fax: 814-452-7005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP017447
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: