Provider Demographics
NPI:1538592696
Name:MCDONOUGH, COURTENAY JAYNE (CRNP)
Entity type:Individual
Prefix:
First Name:COURTENAY
Middle Name:JAYNE
Last Name:MCDONOUGH
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:PO BOX 1052
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0052
Mailing Address - Country:US
Mailing Address - Phone:570-762-6778
Mailing Address - Fax:
Practice Address - Street 1:50 PENNSYLVANIA BLVD
Practice Address - Street 2:
Practice Address - City:WILKES-BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701
Practice Address - Country:US
Practice Address - Phone:570-762-6778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013027363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA476306Medicare PIN