MEDICARE: MONIFA N THELWELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	12567	CT
2	363LG0600X	Gerontology Nurse Practitioner	APN0999269-NP	CO
3	363LG0600X	Gerontology Nurse Practitioner	SP024065	PA

General Provider Information

NPI Number	:	1629734298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONIFA N THELWELL

Provider Business Mailing Address
First Line	:	405 N LINE ST
Second Line	:
City	:	LANSDALE
State	:	PA
Zip	:	19446-2755
Country	:	US
Telephone Number	:	305-978-6086
Fax Number	:	800-564-5952

Provider Business Practice Location Address
First Line	:	1481 MCDONALD AVE FL 2
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-4667
Country	:	US
Telephone Number	:	929-491-7333
Fax Number	:	215-714-2210

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2021
Last Update Date	:	12/05/2023

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