Provider Demographics
NPI:1689911232
Name:LIFE'S JOURNEY OBGYN, PC
Entity Type:Organization
Organization Name:LIFE'S JOURNEY OBGYN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:DUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:814-371-1900
Mailing Address - Street 1:190 WEST PARK AVENUE
Mailing Address - Street 2:SUITE 9
Mailing Address - City:DUBOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801
Mailing Address - Country:US
Mailing Address - Phone:814-371-1900
Mailing Address - Fax:814-503-8568
Practice Address - Street 1:190 WEST PARK AVENUE
Practice Address - Street 2:SUITE 9
Practice Address - City:DUBOIS
Practice Address - State:PA
Practice Address - Zip Code:15801
Practice Address - Country:US
Practice Address - Phone:814-371-1900
Practice Address - Fax:814-503-8568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-15
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014455207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102334099001Medicaid
PAP00813924OtherRAILROAD MEDICARE - PALMETTO
PA158815XF9Medicare PIN