Healthcare Provider Details

I. General information

NPI: 1912137886
Provider Name (Legal Business Name): POLLY SUE GOCKLEY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2009
Last Update Date: 06/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 HIGHLANDS DR STE 100
LITITZ PA
17543-7681
US

IV. Provider business mailing address

409 S 2ND ST STE 2F
HARRISBURG PA
17104-1612
US

V. Phone/Fax

Practice location:
  • Phone: 717-627-4088
  • Fax: 717-627-4089
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP010356
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1024288560002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: