Healthcare Provider Details

I. General information

NPI: 1922213594
Provider Name (Legal Business Name): LISA JO MATHERSON CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 OLD WEST CHESTER PIKE
HAVERTOWN PA
19083-2712
US

IV. Provider business mailing address

271 GREEN HOLLOW RD
GLENMOORE PA
19343-1509
US

V. Phone/Fax

Practice location:
  • Phone: 610-449-8600
  • Fax: 610-449-1302
Mailing address:
  • Phone: 610-913-8008
  • Fax: 610-913-8007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberSPOO3533H
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: