=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508529918
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SYMPHORIEN ANDRE KAMANOU NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2021
-----------------------------------------------------
Last Update Date | 10/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8001 STATE RD
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19136-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-685-8215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26 EDGEMONT AVE
-----------------------------------------------------
City | CLIFTON HEIGHTS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19018-1726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-477-7493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | SP024118
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------