Healthcare Provider Details

I. General information

NPI: 1730300583
Provider Name (Legal Business Name): WENDOLYN RUTHE GRACE RN., CRNP.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 11/27/2023
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 MARYLAND RD
WILLOW GROVE PA
19090
US

IV. Provider business mailing address

2360 MARYLAND RD
WILLOW GROVE PA
19090-1709
US

V. Phone/Fax

Practice location:
  • Phone: 215-657-6776
  • Fax: 267-913-5961
Mailing address:
  • Phone: 215-657-6776
  • Fax: 267-913-5962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP005353B
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: