=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164931630
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHEETAL J GADE CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2017
-----------------------------------------------------
Last Update Date | 12/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 CORNERSTONE DR STE B
-----------------------------------------------------
City | MOUNT JOY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17552-9416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-653-2929
-----------------------------------------------------
Fax | 717-492-0699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 582 ROYER DR
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17601-5186
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-824-3112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | SP018080
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------