Healthcare Provider Details

I. General information

NPI: 1689458903
Provider Name (Legal Business Name): KEREN MIODOVNIK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4395
US

IV. Provider business mailing address

3500 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4395
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1719
  • Fax:
Mailing address:
  • Phone: 215-590-1719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberSP028080
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: