Healthcare Provider Details

I. General information

NPI: 1609401207
Provider Name (Legal Business Name): WONJIN TO NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 ISLAND AVE STE D&E
PHILADELPHIA PA
19153-2300
US

IV. Provider business mailing address

PO BOX 709
GLADWYNE PA
19035-0709
US

V. Phone/Fax

Practice location:
  • Phone: 215-863-6110
  • Fax:
Mailing address:
  • Phone: 484-494-8646
  • Fax: 484-494-0226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number1316902885
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP020119
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: