Healthcare Provider Details

I. General information

NPI: 1992790992
Provider Name (Legal Business Name): BRENDA HAGE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 06/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MUNDY ST
WILKES BARRE PA
18702-6830
US

IV. Provider business mailing address

150 MUNDY ST
WILKES BARRE PA
18702-6830
US

V. Phone/Fax

Practice location:
  • Phone: 570-824-0930
  • Fax: 570-824-7755
Mailing address:
  • Phone: 570-824-0930
  • Fax: 570-824-7755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberTP-003758-B
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: