1265554620 NPI number — JACQUELYN AVERY ALFONSI COTA

Table of content: JACQUELYN AVERY ALFONSI COTA (NPI 1265554620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265554620 NPI number — JACQUELYN AVERY ALFONSI COTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALFONSI
Provider First Name:
JACQUELYN
Provider Middle Name:
AVERY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
COTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265554620
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 REDFORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORELAND
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19075-1926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-886-4815
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8833 STENTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WYNDMOOR
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19038-8319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-836-2100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  OP001877L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)