Basic Information
| Provider Information | |||||||||
| NPI: | 1649748385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDERMOTT | ||||||||
| FirstName: | LEEANN | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 TRIPP MNR | ||||||||
| Address2: | |||||||||
| City: | FORTY FORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187044025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702871558 | ||||||||
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| Practice Location | |||||||||
| Address1: | 420 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706215000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2018 | ||||||||
| LastUpdateDate: | 11/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X | RN303680L | PA | N | Nursing Service Providers | Registered Nurse | Emergency | 363LF0000X | SP019327 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | SP019327 | 01 | PA | CRNP | OTHER | RN30368L | 01 | PA | RN | OTHER |