Provider Demographics
NPI:1093449373
Name:RATAJCZAK, NICOLE (CRNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RATAJCZAK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:WENNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:888-647-9600
Mailing Address - Fax:
Practice Address - Street 1:1705 WARREN AVE STE 101-103
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-2647
Practice Address - Country:US
Practice Address - Phone:570-321-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP025878363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner