Basic Information
| Provider Information | |||||||||
| NPI: | 1184747776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THORNTON-BOWMER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ROSALIND | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN-BC, CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 WISSAHICKON AVE | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191444248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2675973600 | ||||||||
| FaxNumber: | 2675973622 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 WISSAHICKON AVE | ||||||||
| Address2: | SUITE 119 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191444248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158439720 | ||||||||
| FaxNumber: | 2158437313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN516639L | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | SP009389 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.