MEDICARE: LA SALLE ACADEMY

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	363LP0200X	Pediatric Nurse Practitioner

General Provider Information

NPI Number	:	1659747863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA SALLE ACADEMY

Provider Business Mailing Address
First Line	:	970 SPROUL RD
Second Line	:
City	:	BRYN MAWR
State	:	PA
Zip	:	19010-2026
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1434 N 2ND ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19122-3802
Country	:	US
Telephone Number	:	215-739-5804
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JULIE EMIG
Credential	:
Telephone Number	:	215-687-6286

Provider Enumeration Date	:	08/12/2015
Last Update Date	:	08/12/2015

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Directions to “LA SALLE ACADEMY ” Practice Location

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