Basic Information
| Provider Information | |||||||||
| NPI: | 1609422963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANNO | ||||||||
| FirstName: | JILLIAN | ||||||||
| MiddleName: | BLAKE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6952 WERTZVILLE RD | ||||||||
| Address2: | |||||||||
| City: | ENOLA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170251037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172754969 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 52 RED HILL CT | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170748706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175673151 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2019 | ||||||||
| LastUpdateDate: | 08/13/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP020506 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.