=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104466853
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH KNUDSEN CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2020
-----------------------------------------------------
Last Update Date | 07/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3701 MARKET STREET 7TH FLOOR, SUITE 741
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-5502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-428-9058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3701 MARKET STREET 7TH FLOOR
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-428-9058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | SP026449
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------