Healthcare Provider Details

I. General information

NPI: 1538375381
Provider Name (Legal Business Name): KATHLEEN REALE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 CHERRY ST
PHILADELPHIA PA
19106-1803
US

IV. Provider business mailing address

1611 WINDSOR CT
LANSDALE PA
19446-4339
US

V. Phone/Fax

Practice location:
  • Phone: 800-974-6383
  • Fax:
Mailing address:
  • Phone: 215-361-9864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberOC009683
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: