Healthcare Provider Details

I. General information

NPI: 1164669487
Provider Name (Legal Business Name): ELLEN DIANE BURKHALTER RN, CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2009
Last Update Date: 01/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 A ST
PHILADELPHIA PA
19134-1043
US

IV. Provider business mailing address

3601 A ST
PHILADELPHIA PA
19134-1043
US

V. Phone/Fax

Practice location:
  • Phone: 215-427-4820
  • Fax: 215-427-4822
Mailing address:
  • Phone: 215-427-4820
  • Fax: 215-427-4822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberSP00970
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: