Provider Demographics
NPI:1427531144
Name:TETZLAFF, IRENE
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:TETZLAFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 S LANCASTER ST
Mailing Address - Street 2:
Mailing Address - City:ANNVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17003-2137
Mailing Address - Country:US
Mailing Address - Phone:717-304-8633
Mailing Address - Fax:
Practice Address - Street 1:2500 LISBURN RD
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-8005
Practice Address - Country:US
Practice Address - Phone:717-884-6487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-09
Last Update Date:2018-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP019136363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health