Healthcare Provider Details

I. General information

NPI: 1972333938
Provider Name (Legal Business Name): CHENIECE DE ROSA CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6212 WALNUT ST
PHILADELPHIA PA
19139-3706
US

IV. Provider business mailing address

6212 WALNUT ST
PHILADELPHIA PA
19139-3706
US

V. Phone/Fax

Practice location:
  • Phone: 215-476-6264
  • Fax:
Mailing address:
  • Phone: 610-835-2471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP030221
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: