Healthcare Provider Details

I. General information

NPI: 1376002162
Provider Name (Legal Business Name): WENDY ARIATY TIBURCIO-MATEO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PHILADELPHIA AVE
SHILLINGTON PA
19607-2764
US

IV. Provider business mailing address

522 S 16TH ST
READING PA
19606-2509
US

V. Phone/Fax

Practice location:
  • Phone: 484-955-4482
  • Fax:
Mailing address:
  • Phone: 484-955-4482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP019918
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: