MEDICARE: MS. CONNEILA AIYSHA GARRIS LPN

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	164W00000X	Licensed Practical Nurse	PN302036	PA

General Provider Information

NPI Number	:	1750248480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CONNEILA AIYSHA GARRIS LPN

Provider Business Mailing Address
First Line	:	1902 W GODFREY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19141
Country	:	US
Telephone Number	:	267-393-1714
Fax Number	:

Provider Business Practice Location Address
First Line	:	7307 BUIST AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19153-2204
Country	:	US
Telephone Number	:	610-998-5794
Fax Number	:

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

Provider Enumeration Date	:	01/06/2026
Last Update Date	:	01/06/2026

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