Basic Information
| Provider Information | |||||||||
| NPI: | 1992179030 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUFF | ||||||||
| FirstName: | JACQUELYN | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178224903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702716144 | ||||||||
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| Practice Location | |||||||||
| Address1: | 425 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178151480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704161890 | ||||||||
| FaxNumber: | 5704161892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2015 | ||||||||
| LastUpdateDate: | 08/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP015193 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP2300X | SP015193 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 467939 | 01 | PA | MEDICARE | OTHER |