Healthcare Provider Details

I. General information

NPI: 1003601584
Provider Name (Legal Business Name): TALIA LAGRAVINESE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W LANCASTER AVE
PAOLI PA
19301-1763
US

IV. Provider business mailing address

3803 W CHESTER PIKE STE 160
NEWTOWN SQUARE PA
19073-2336
US

V. Phone/Fax

Practice location:
  • Phone: 484-565-1510
  • Fax: 484-565-1513
Mailing address:
  • Phone: 484-337-1632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberSP031454
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP031454
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: