Healthcare Provider Details

I. General information

NPI: 1770352650
Provider Name (Legal Business Name): SUSAN ELIZABETH THOMPSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 WOODLAND AVE
PHILADELPHIA PA
19104-4551
US

IV. Provider business mailing address

2505 MANSFIELD AVE
DREXEL HILL PA
19026-1016
US

V. Phone/Fax

Practice location:
  • Phone: 215-823-4175
  • Fax: 218-823-4411
Mailing address:
  • Phone: 610-246-0024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN322251L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: