Healthcare Provider Details

I. General information

NPI: 1679846794
Provider Name (Legal Business Name): THERESA DOUSE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2012
Last Update Date: 02/06/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 W STATE STREET DIABETES MANAGEMENT
DOYLESTOWN PA
18901
US

IV. Provider business mailing address

PO BOX 829641
PHILADELPHIA PA
19182-9641
US

V. Phone/Fax

Practice location:
  • Phone: 215-345-2172
  • Fax: 215-345-2525
Mailing address:
  • Phone: 267-370-5296
  • Fax: 215-230-3725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP011803
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberSP011803
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: