Provider Demographics
NPI:1922336452
Name:PALACHICK, JENICE DIANE (CRNP)
Entity Type:Individual
Prefix:MS
First Name:JENICE
Middle Name:DIANE
Last Name:PALACHICK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MRS
Other - First Name:JENICE
Other - Middle Name:D
Other - Last Name:PALACHICK FRANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5352
Mailing Address - Fax:
Practice Address - Street 1:4035 ELECTRIC RD STE A
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-8449
Practice Address - Country:US
Practice Address - Phone:540-772-8670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185916363LF0000X
PASP010477363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD541024000Medicaid
PA25-1716306OtherHEALTHNET/TRICARE
PA25-1716306OtherINTERGROUP
PAP00802876OtherRAILROAD MEDICARE
PA25-1716306OtherDEVON
PA50090234OtherCAPITAL BLUECROSS
MD679MOtherMEDICARE GROUP #
PA25-1716306OtherMULTIPLAN/PHCS
PA867633OtherMEDICARE GROUP #
PA1007307260034OtherMEDICAID GROUP #
PA102416560 0001Medicaid
PASP010477OtherLICENSE
PASP010477OtherLICENSE
PA102416560 0001Medicaid