=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861374068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KASEY ALEXIS TANKELEWICZ CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2025
-----------------------------------------------------
Last Update Date | 07/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 73 N MAPLE AVE
-----------------------------------------------------
City | MARLTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08053-1782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-352-6660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15033 ENDICOTT ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19116-1530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-690-4879
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | SP033169
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------