Healthcare Provider Details

I. General information

NPI: 1780167940
Provider Name (Legal Business Name): AMY BETH BUSH CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date: 10/03/2018
Reactivation Date: 10/10/2018

III. Provider practice location address

4610 E STREET RD
FEASTERVILLE TREVOSE PA
19053-6612
US

IV. Provider business mailing address

240 FITZWATERTOWN RD
WILLOW GROVE PA
19090-2332
US

V. Phone/Fax

Practice location:
  • Phone: 610-647-0330
  • Fax: 267-495-1707
Mailing address:
  • Phone: 610-647-0330
  • Fax: 267-495-1707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP019362
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN545080
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: