Healthcare Provider Details

I. General information

NPI: 1619357605
Provider Name (Legal Business Name): CERTIFIED WOUND CARE SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1356 MAIN ST
NORTHAMPTON PA
18067-1798
US

IV. Provider business mailing address

1356 MAIN ST
NORTHAMPTON PA
18067-1798
US

V. Phone/Fax

Practice location:
  • Phone: 610-262-3464
  • Fax: 610-262-1404
Mailing address:
  • Phone: 610-262-3464
  • Fax: 610-262-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP013454
License Number StatePA

VIII. Authorized Official

Name: JOANNE LABIAK
Title or Position: ADMINISTRATOR
Credential: CRNP
Phone: 610-262-3464