=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396119673
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERI LYNN GONGAWARE-FITZPATRICK CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2015
-----------------------------------------------------
Last Update Date | 02/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 CEDAR RIDGE DR SUITE 212
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15205-9691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-317-0216
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 171 SONNIE DR PO BOX 25
-----------------------------------------------------
City | CRABTREE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15624-0025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-558-0592
-----------------------------------------------------
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 | SP 015276
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------