Healthcare Provider Details

I. General information

NPI: 1861660110
Provider Name (Legal Business Name): NICHOLE REID CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 MADISON AVE FL 1
MOUNT HOLLY NJ
08060-2099
US

IV. Provider business mailing address

3400 SPRUCE ST GROUND FLOOR DULLES
PHILADELPHIA PA
19104-4206
US

V. Phone/Fax

Practice location:
  • Phone: 609-914-6000
  • Fax:
Mailing address:
  • Phone: 215-662-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP009748
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00331600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: