=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235945551
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. MARYKUTTY EDWARD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2024
-----------------------------------------------------
Last Update Date | 04/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2901 JOLLY RD
-----------------------------------------------------
City | PLYMOUTH MEETING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19462-2324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-272-8221
-----------------------------------------------------
Fax | 610-272-5655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 552 WILLIAM PENN WAY
-----------------------------------------------------
City | LANSDALE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19446-4174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-222-0468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | SP031472
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------