Healthcare Provider Details

I. General information

NPI: 1750756540
Provider Name (Legal Business Name): REBECCA KEUCH CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2015
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 N BROAD ST STE 4
PHILADELPHIA PA
19121-3429
US

IV. Provider business mailing address

1700 N BROAD ST STE 4
PHILADELPHIA PA
19121-3429
US

V. Phone/Fax

Practice location:
  • Phone: 215-204-7500
  • Fax: 215-204-4660
Mailing address:
  • Phone: 215-204-7500
  • Fax: 215-204-4660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP015304
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: