Healthcare Provider Details

I. General information

NPI: 1114416179
Provider Name (Legal Business Name): DEVON ELIZABETH HURLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2018
Last Update Date: 05/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 SOUTH ST
PHILADELPHIA PA
19146-1636
US

IV. Provider business mailing address

1424 KENILWORTH ST
PHILADELPHIA PA
19146-2208
US

V. Phone/Fax

Practice location:
  • Phone: 267-239-5637
  • Fax: 267-455-0825
Mailing address:
  • Phone: 215-514-6658
  • Fax: 267-455-0825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN006063
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: