Basic Information
| Provider Information | |||||||||
| NPI: | 1659505931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALCHUNE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178224903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702716144 | ||||||||
| FaxNumber: | 5702716578 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PITTSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 186401916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706540880 | ||||||||
| FaxNumber: | 5706559857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2009 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OT011805 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 440771 | 01 | PA | MEDICARE AA # | OTHER |