Healthcare Provider Details

I. General information

NPI: 1295127132
Provider Name (Legal Business Name): MARYBELL RODRIGUEZ CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 OLD YORK RD
PHILADELPHIA PA
19141-3030
US

IV. Provider business mailing address

5501 OLD YORK RD
PHILADELPHIA PA
19141-3018
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-6178
  • Fax:
Mailing address:
  • Phone: 215-456-6178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP014719
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: