Provider Demographics
NPI:1487677084
Name:CLANCY, CHRISTINE NIERODA (CRNP)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:NIERODA
Last Name:CLANCY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 S. 9TH STREET
Mailing Address - Street 2:SUITE 600
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-6810
Mailing Address - Country:US
Mailing Address - Phone:215-955-1925
Mailing Address - Fax:215-928-3160
Practice Address - Street 1:211 S. 9TH STREET
Practice Address - Street 2:SUITE 600
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-955-1925
Practice Address - Fax:215-928-3160
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP004645C363LA2200X, 363LP2300X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103075213Medicaid
PAS46826Medicare UPIN
PA103075213Medicaid
S46826Medicare UPIN