Healthcare Provider Details

I. General information

NPI: 1568801009
Provider Name (Legal Business Name): ROSE-THERESE N REBUSTILLO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 CHESTNUT ST SUITE 210
PHILADELPHIA PA
19106-2614
US

IV. Provider business mailing address

1101 SOUTH ST UNIT B
PHILADELPHIA PA
19147-1956
US

V. Phone/Fax

Practice location:
  • Phone: 267-322-7700
  • Fax:
Mailing address:
  • Phone: 201-394-5502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN624686
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: