Healthcare Provider Details

I. General information

NPI: 1013636729
Provider Name (Legal Business Name): LISA MARIE HARRELSON DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4453 CASTOR AVE STE B
PHILADELPHIA PA
19124-3846
US

IV. Provider business mailing address

4453 CASTOR AVE STE B
PHILADELPHIA PA
19124-3846
US

V. Phone/Fax

Practice location:
  • Phone: 215-744-2266
  • Fax:
Mailing address:
  • Phone: 215-744-2266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP026175
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: