Healthcare Provider Details

I. General information

NPI: 1528804739
Provider Name (Legal Business Name): TYLER JAMES JANNONE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N FAIRVIEW ST
LOCK HAVEN PA
17745-2390
US

IV. Provider business mailing address

839 W UNION ST
CANTON PA
17724-7463
US

V. Phone/Fax

Practice location:
  • Phone: 570-484-2027
  • Fax:
Mailing address:
  • Phone: 570-916-2699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

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: