Healthcare Provider Details

I. General information

NPI: 1346066859
Provider Name (Legal Business Name): MERCEDES JULIA DETTRA PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2024
Last Update Date: 11/30/2024
Certification Date: 11/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N 49TH ST
PHILADELPHIA PA
19139-2718
US

IV. Provider business mailing address

913 S 51ST ST APT 4
PHILADELPHIA PA
19143-3260
US

V. Phone/Fax

Practice location:
  • Phone: 215-471-2600
  • Fax:
Mailing address:
  • Phone: 267-650-5454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP031168
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: