Healthcare Provider Details

I. General information

NPI: 1689875098
Provider Name (Legal Business Name): LORETTA COLFORD REILLY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34TH ST AND CIVIC CENTER BLVD
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

302 KEATLEY DR
MOUNT LAUREL NJ
08054-5131
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-0789
  • Fax: 215-590-6301
Mailing address:
  • Phone: 856-802-6407
  • Fax: 215-590-6301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN251317L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: