Basic Information
Provider Information | |||||||||
NPI: | 1407594740 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KNOCK | ||||||||
FirstName: | CYNTHIA | ||||||||
MiddleName: | RENEE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SHAMBACH | ||||||||
OtherFirstName: | CYNTHIA | ||||||||
OtherMiddleName: | RENEE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 523 N 4TH ST | ||||||||
Address2: |   | ||||||||
City: | SUNBURY | ||||||||
State: | PA | ||||||||
PostalCode: | 178011209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5702862482 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 45 ROUTE 11 | ||||||||
Address2: |   | ||||||||
City: | SHAMOKIN DAM | ||||||||
State: | PA | ||||||||
PostalCode: | 178769116 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8887264774 | ||||||||
FaxNumber: | 5703625112 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2022 | ||||||||
LastUpdateDate: | 05/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X |   | PA | Y |   |   |   |   |
No ID Information.