Provider Demographics
NPI:1831659556
Name:FEDORCHAK, RENEE M
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:M
Last Name:FEDORCHAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:M
Other - Last Name:WALIGUN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP-C
Mailing Address - Street 1:3651 CHASE RD
Mailing Address - Street 2:
Mailing Address - City:SHAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18708-9737
Mailing Address - Country:US
Mailing Address - Phone:570-704-9695
Mailing Address - Fax:
Practice Address - Street 1:890 BETHEL HILL RD
Practice Address - Street 2:
Practice Address - City:SHICKSHINNY
Practice Address - State:PA
Practice Address - Zip Code:18655-3706
Practice Address - Country:US
Practice Address - Phone:570-991-6256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP019638363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily