Healthcare Provider Details

I. General information

NPI: 1558094052
Provider Name (Legal Business Name): AMANDA MUMMERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2022
Last Update Date: 10/26/2022
Certification Date: 10/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CHILDREN'S HOSPITAL OF PHILADELPHIA 550 SOUTH GODDARD BLVD
KING OF PRUSSIA PA
19406
US

IV. Provider business mailing address

4701 PINE ST APT F11
PHILADELPHIA PA
19143-7009
US

V. Phone/Fax

Practice location:
  • Phone: 646-812-3870
  • Fax:
Mailing address:
  • Phone: 646-812-3870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberSP026192
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number172417
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: