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General NPI Number Information
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NPI Number | 1205792629
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Entity Type | Individual
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Provider Name | ANNALIESE JUSTINE GORHAM CRNP, FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 12/30/2025
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Last Update Date | 12/30/2025
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Provider Practice Location Address
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Address Line | 3141 CHESTNUT ST
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City | PHILADELPHIA
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State | PA
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Zip | 19104-2875
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Country | US
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Telephone | 215-895-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 556 MAIN ST APT C3
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City | SCHWENKSVILLE
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State | PA
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Zip | 19473-1021
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Country | US
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Telephone | 315-484-8434
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Fax |
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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 | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 2025089303
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License Number State | PA
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