MEDICARE: MRS. JACQUELYN ELIZABETH MOWDAY NURSE PRACTITIONER

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	363LW0102X	Women's Health Nurse Practitioner	SP005873G	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	232359401	OTHER	PW	MAIN LINE HEALTHCARE

General Provider Information

NPI Number	:	1144296948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JACQUELYN ELIZABETH MOWDAY NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	1991 SPROUL RD
Second Line	:	SUITE 200
City	:	BROOMALL
State	:	PA
Zip	:	19008-3512
Country	:	US
Telephone Number	:	610-325-1350
Fax Number	:	610-325-1357

Provider Business Practice Location Address
First Line	:	1991 SPROUL RD
Second Line	:	SUITE 200
City	:	BROOMALL
State	:	PA
Zip	:	19008-3512
Country	:	US
Telephone Number	:	610-325-1350
Fax Number	:	610-325-1357

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

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	08/24/2017

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