Healthcare Provider Details

I. General information

NPI: 1083942106
Provider Name (Legal Business Name): CAROL L TANZIO CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 10/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 S NEW MIDDLETOWN RD MOB, 1ST FLOOR
MEDIA PA
19063-5255
US

IV. Provider business mailing address

176 S NEW MIDDLETOWN RD
MEDIA PA
19063-5255
US

V. Phone/Fax

Practice location:
  • Phone: 610-627-3690
  • Fax: 610-627-3684
Mailing address:
  • Phone: 610-627-3690
  • Fax: 610-627-3684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP010610
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN505951L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: