Healthcare Provider Details

I. General information

NPI: 1275141848
Provider Name (Legal Business Name): LONDON NICOLE MCKENNA CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 GALLAGHER DR
PLAINS PA
18705-1146
US

IV. Provider business mailing address

627 WALES ST
SCRANTON PA
18508-1331
US

V. Phone/Fax

Practice location:
  • Phone: 570-970-1030
  • Fax: 570-970-0511
Mailing address:
  • Phone: 570-780-6821
  • Fax: 570-970-0511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP022228
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: