Provider Demographics
NPI:1588255798
Name:WERNICKI, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WERNICKI
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 1:621 HAWTHORNE TRCE
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:PA
Mailing Address - Zip Code:16415-1723
Mailing Address - Country:US
Mailing Address - Phone:814-490-9389
Mailing Address - Fax:
Practice Address - Street 1:621 HAWTHORNE TRCE
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:PA
Practice Address - Zip Code:16415-1723
Practice Address - Country:US
Practice Address - Phone:814-490-9389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-30
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA596385163W00000X
PA136142367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse