MEDICARE: MARY LONDON FNP

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	163W00000X	Registered Nurse	RN695130	PA
2	363LF0000X	Family Nurse Practitioner	SP019604	PA

General Provider Information

NPI Number	:	1699245498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY LONDON FNP

Provider Business Mailing Address
First Line	:	2534 S 18TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-3701
Country	:	US
Telephone Number	:	215-463-4363
Fax Number	:

Provider Business Practice Location Address
First Line	:	2534 S 18TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-3701
Country	:	US
Telephone Number	:	215-463-4363
Fax Number	:

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

Provider Enumeration Date	:	12/05/2018
Last Update Date	:	12/05/2018

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