Healthcare Provider Details

I. General information

NPI: 1710227137
Provider Name (Legal Business Name): JACQUELINE KOBAL CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 MEADE ST
DUNMORE PA
18512-3169
US

IV. Provider business mailing address

1100 MEADE ST
DUNMORE PA
18512-3169
US

V. Phone/Fax

Practice location:
  • Phone: 570-342-3675
  • Fax: 570-342-3316
Mailing address:
  • Phone: 570-342-3675
  • Fax: 570-342-3316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP012774
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: