Healthcare Provider Details

I. General information

NPI: 1649788092
Provider Name (Legal Business Name): JENNIFER LYNN DRAKE DNP, CRNP, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER LYNN DIVIRGILIO CRNP

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E BROAD ST
HAZLETON PA
18201-6835
US

IV. Provider business mailing address

700 E BROAD ST
HAZLETON PA
18201-6835
US

V. Phone/Fax

Practice location:
  • Phone: 570-501-4000
  • Fax:
Mailing address:
  • Phone: 570-501-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP018049
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: