Healthcare Provider Details

I. General information

NPI: 1245826692
Provider Name (Legal Business Name): MARYLANDE REGIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2020
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 GLENWOOD AVE
EAST LANSDOWNE PA
19050-2512
US

IV. Provider business mailing address

401 GLENWOOD AVE
EAST LANSDOWNE PA
19050-2512
US

V. Phone/Fax

Practice location:
  • Phone: 267-235-5089
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number257498
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN703181
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: