Provider Demographics
NPI:1396430831
Name:LIN, WANNI (CRNP)
Entity type:Individual
Prefix:
First Name:WANNI
Middle Name:
Last Name:LIN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:75 E DERRY RD
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2705
Practice Address - Country:US
Practice Address - Phone:717-835-0700
Practice Address - Fax:717-835-0702
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PARN714958163W00000X
PASP027679363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1041873030001Medicaid