Provider Demographics
NPI:1629368659
Name:MAO, JIANNONG
Entity Type:Individual
Prefix:
First Name:JIANNONG
Middle Name:
Last Name:MAO
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 1:2386 SAGAMORE DR
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-2412
Mailing Address - Country:US
Mailing Address - Phone:814-231-3003
Mailing Address - Fax:
Practice Address - Street 1:1536 N ATHERTON ST
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-3041
Practice Address - Country:US
Practice Address - Phone:814-237-4133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP440707183500000X
CARPH54187183500000X
NV15514183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist