=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073877171
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REGINA DENISE ROSS ACNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2012
-----------------------------------------------------
Last Update Date | 07/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 SPRING GARDEN ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19130-4067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-606-6400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1106B RALSTON DR
-----------------------------------------------------
City | MOUNT LAUREL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08054-3390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-670-9730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | SP011804
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ00366600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------