Healthcare Provider Details

I. General information

NPI: 1922532787
Provider Name (Legal Business Name): JOAN HANISCO CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

IV. Provider business mailing address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-4600
  • Fax: 215-707-9697
Mailing address:
  • Phone: 215-707-4600
  • Fax: 215-707-9697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP017208
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: