Healthcare Provider Details

I. General information

NPI: 1053927434
Provider Name (Legal Business Name): MARY ANN TESTADO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9219 BLUE GRASS RD # APPT1
PHILADELPHIA PA
19114-4370
US

IV. Provider business mailing address

9219 BLUE GRASS RD # APPT1
PHILADELPHIA PA
19114-4370
US

V. Phone/Fax

Practice location:
  • Phone: 215-245-2131
  • Fax:
Mailing address:
  • Phone: 215-245-2131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN572026
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: