Healthcare Provider Details

I. General information

NPI: 1164497087
Provider Name (Legal Business Name): HEATHER TENBROCK KERN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

552A LANCASTER AVE
BERWYN PA
19312-1635
US

IV. Provider business mailing address

552A LANCASTER AVE
BERWYN PA
19312-1635
US

V. Phone/Fax

Practice location:
  • Phone: 610-644-7100
  • Fax: 610-644-7111
Mailing address:
  • Phone: 610-644-7100
  • Fax: 610-644-7111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOA002074
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA051627
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: