Healthcare Provider Details

I. General information

NPI: 1669255220
Provider Name (Legal Business Name): WILLIE HARLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4024 N DARIEN ST
PHILADELPHIA PA
19140-2237
US

IV. Provider business mailing address

4024 N DARIEN ST
PHILADELPHIA PA
19140-2237
US

V. Phone/Fax

Practice location:
  • Phone: 267-778-8390
  • Fax:
Mailing address:
  • Phone: 267-778-8390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number169194
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: