Provider Demographics
NPI:1295766046
Name:GAETANO, MARIE SUSAN (CRNP)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:SUSAN
Last Name:GAETANO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:SUSAN
Other - Last Name:WALSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3 WALNUT ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LEMOYNE
Mailing Address - State:PA
Mailing Address - Zip Code:17043-1168
Mailing Address - Country:US
Mailing Address - Phone:717-761-0208
Mailing Address - Fax:717-761-2023
Practice Address - Street 1:4470 VALLEY ST
Practice Address - Street 2:
Practice Address - City:ENOLA
Practice Address - State:PA
Practice Address - Zip Code:17025-1443
Practice Address - Country:US
Practice Address - Phone:717-732-8883
Practice Address - Fax:717-732-1640
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP008299363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA158044Medicare PIN