Healthcare Provider Details

I. General information

NPI: 1295779742
Provider Name (Legal Business Name): SUZANNE WILLARD CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1427 VINE ST 3RD FLR
PHILADELPHIA PA
19102-1031
US

IV. Provider business mailing address

6123 WAYNE AVE
PHILADELPHIA PA
19144-6103
US

V. Phone/Fax

Practice location:
  • Phone: 215-762-2530
  • Fax: 215-762-2531
Mailing address:
  • Phone: 215-768-0337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberVP001737C
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: