Healthcare Provider Details

I. General information

NPI: 1083070601
Provider Name (Legal Business Name): JOANNA WISHNOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 RIDGE AVE
PHILADELPHIA PA
19128-2459
US

IV. Provider business mailing address

1632 PINE ST
PHILADELPHIA PA
19103-6711
US

V. Phone/Fax

Practice location:
  • Phone: 215-333-4300
  • Fax:
Mailing address:
  • Phone: 215-735-7992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License NumberSP015593
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP015593
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberSP015593
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: