Healthcare Provider Details

I. General information

NPI: 1164070769
Provider Name (Legal Business Name): JUDITH LYNNE RAPPAPORT RN MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 S BROAD ST FL 3
PHILADELPHIA PA
19146-1750
US

IV. Provider business mailing address

1718 MELON ST
PHILADELPHIA PA
19130-3303
US

V. Phone/Fax

Practice location:
  • Phone: 215-680-3520
  • Fax:
Mailing address:
  • Phone: 215-680-3520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberRN290839L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: