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General NPI Number Information
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NPI Number | 1063662849
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Entity Type | Individual
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Provider Name | MARY SUE NICHOLSON CRNP
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Gender | Female
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Dates
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Enumeration Date | 09/29/2008
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Last Update Date | 09/29/2008
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Provider Practice Location Address
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Address Line | 4098 EDGMONT AVE
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City | BROOKHAVEN
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State | PA
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Zip | 19015-2211
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Country | US
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Telephone | 866-825-3227
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Fax | 484-450-2617
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Provider Business Mailing Address
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Address Line | 161 WASHINGTON ST EIGHT TOWER BRIDGE STE 1400
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City | CONSHOHOCKEN
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State | PA
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Zip | 19428-2083
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Country | US
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Telephone | 866-825-3227
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Fax | 484-450-2617
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | SP007470
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License Number State | PA
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