Provider Demographics
NPI:1225507270
Name:GANZEKAUFER, NICOLE MARIE (CNM, WHNP-BC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:GANZEKAUFER
Suffix:
Gender:F
Credentials:CNM, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 THOMAS JEFFERSON RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-1029
Mailing Address - Country:US
Mailing Address - Phone:718-314-4595
Mailing Address - Fax:
Practice Address - Street 1:1138 GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:CHRISTIANA
Practice Address - State:PA
Practice Address - Zip Code:17509-9720
Practice Address - Country:US
Practice Address - Phone:717-786-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMWO10504176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007781850003Medicaid