Provider Demographics
NPI:1013222413
Name:VANDERKLOK, ELEANOR LYNN (CRNP)
Entity Type:Individual
Prefix:MS
First Name:ELEANOR
Middle Name:LYNN
Last Name:VANDERKLOK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 CHESTNUT ST
Mailing Address - Street 2:SUITE 320A
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4216
Mailing Address - Country:US
Mailing Address - Phone:215-955-8874
Mailing Address - Fax:
Practice Address - Street 1:925 CHESTNUT ST
Practice Address - Street 2:SUITE 320A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4216
Practice Address - Country:US
Practice Address - Phone:215-955-8874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010656363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102894693Medicaid
PA202832Medicare PIN