Healthcare Provider Details

I. General information

NPI: 1134874738
Provider Name (Legal Business Name): NINA MCILHENNY RN, BSN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2022
Last Update Date: 02/14/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12520 RICHTON RD
PHILADELPHIA PA
19154-1916
US

IV. Provider business mailing address

12520 RICHTON RD
PHILADELPHIA PA
19154-1916
US

V. Phone/Fax

Practice location:
  • Phone: 215-350-1115
  • Fax:
Mailing address:
  • Phone: 215-350-1115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-303761
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: