Healthcare Provider Details

I. General information

NPI: 1619347655
Provider Name (Legal Business Name): TESSA KOVICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LANCASTER AVE STE 114
WYNNEWOOD PA
19096
US

IV. Provider business mailing address

100 E LANCASTER AVE STE 114
WYNNEWOOD PA
19096-3450
US

V. Phone/Fax

Practice location:
  • Phone: 484-337-2580
  • Fax: 610-647-2006
Mailing address:
  • Phone: 484-337-2580
  • Fax: 610-647-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN596763
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP015513
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: