Basic Information
| Provider Information | |||||||||
| NPI: | 1609822824 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LICHNER | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | STOUDT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1650 VALLEY CENTER PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180172344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848844436 | ||||||||
| FaxNumber: | 4848844444 | ||||||||
| Practice Location | |||||||||
| Address1: | 6900 HAMILTON BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | TREXLERTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104020170 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP000994 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 197466 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 197466 | 01 | PA | KEYSTONE CENTRAL | OTHER | 50029571 | 01 | PA | CAPITAL | OTHER |