Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | SP016200 | PA |
NPI | 1043662497 |
---|---|
Provider Name | Mrs. Jennifer Lynn Black-Waerig |
First Address | Philadelphia, PA 19134-1011 |
Second Address | Philadelphia, PA 19134-1011 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2016 |
Last Update Date | 11/07/2016 |