Healthcare Provider Details

I. General information

NPI: 1114626561
Provider Name (Legal Business Name): JUSTINE KOHLEPP LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2023
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 N FRONT ST
PHILADELPHIA PA
19122-1705
US

IV. Provider business mailing address

136 DIAMOND ST
PHILADELPHIA PA
19122-1797
US

V. Phone/Fax

Practice location:
  • Phone: 215-425-8100
  • Fax: 267-861-6410
Mailing address:
  • Phone: 215-426-8100
  • Fax: 267-861-6410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN295851
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: