=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265240592
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEVYN BRITTANY NICKERSON CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2024
-----------------------------------------------------
Last Update Date | 01/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12351 PERRY HWY
-----------------------------------------------------
City | WEXFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15090-8344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-939-3673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 154 WALNUT DR
-----------------------------------------------------
City | BADEN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15005-2356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-312-5793
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | RN709595
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 153128
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------