Healthcare Provider Details

I. General information

NPI: 1922475912
Provider Name (Legal Business Name): JESSICA W CONNELL CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2015
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 PAOLI PIKE REHABILITATION ASSOCIATES OF THE MAIN LINE
MALVERN PA
19355-3311
US

IV. Provider business mailing address

414 PAOLI PIKE REHABILITATION ASSOCIATES OF THE MAIN LINE
MALVERN PA
19355-3311
US

V. Phone/Fax

Practice location:
  • Phone: 484-596-3969
  • Fax:
Mailing address:
  • Phone: 484-596-3969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP014900
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN587962
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: