MEDICARE: MARY SUE NICHOLSON CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	SP007470	PA

General Provider Information

NPI Number	:	1063662849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY SUE NICHOLSON CRNP

Provider Business Mailing Address
First Line	:	161 WASHINGTON ST
Second Line	:	EIGHT TOWER BRIDGE STE 1400
City	:	CONSHOHOCKEN
State	:	PA
Zip	:	19428-2083
Country	:	US
Telephone Number	:	866-825-3227
Fax Number	:	484-450-2617

Provider Business Practice Location Address
First Line	:	4098 EDGMONT AVE
Second Line	:
City	:	BROOKHAVEN
State	:	PA
Zip	:	19015-2211
Country	:	US
Telephone Number	:	866-825-3227
Fax Number	:	484-450-2617

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2008
Last Update Date	:	09/29/2008

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