Provider Demographics
NPI:1720414261
Name:MUSGROVE, BERNADETTE (LPN)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:MUSGROVE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 FREETHY POND ROAD
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431
Mailing Address - Country:US
Mailing Address - Phone:570-647-6807
Mailing Address - Fax:
Practice Address - Street 1:238 DELAWARE STREET
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:PA
Practice Address - Zip Code:18421
Practice Address - Country:US
Practice Address - Phone:570-785-2624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA291391164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA291391OtherLPN