Basic Information
| Provider Information | |||||||||
| NPI: | 1346814175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNACK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYN | ||||||||
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| Credential: | DMPNA, CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2305 KANAWHA TER APT 102 | ||||||||
| Address2: | |||||||||
| City: | SAINT ALBANS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 251775201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439969566 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 GRESHAM DR | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573883000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2021 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001299340 | VA | N | Nursing Service Providers | Registered Nurse | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.