Basic Information
| Provider Information | |||||||||
| NPI: | 1649667700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVIN | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 CHESTNUT ST | ||||||||
| Address2: | SUITE 620 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556864 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1015 CHESTNUT ST | ||||||||
| Address2: | SUITE 620 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556864 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2015 | ||||||||
| LastUpdateDate: | 04/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.