Healthcare Provider Details

I. General information

NPI: 1558084640
Provider Name (Legal Business Name): NICHOLE REZK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BROAD ST
JOHNSTOWN PA
15906-2745
US

IV. Provider business mailing address

135 DUTCH RD
CARROLLTOWN PA
15722-6400
US

V. Phone/Fax

Practice location:
  • Phone: 814-535-6000
  • Fax:
Mailing address:
  • Phone: 814-241-9843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN618058
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: