Basic Information
| Provider Information | |||||||||
| NPI: | 1710311378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REILY | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DOOLEY | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2500 MARYLAND RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | WILLOW GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190901225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154814143 | ||||||||
| FaxNumber: | 2154816790 | ||||||||
| Practice Location | |||||||||
| Address1: | 3941 COMMERCE AVE | ||||||||
| Address2: | |||||||||
| City: | WILLOW GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190901104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154814000 | ||||||||
| FaxNumber: | 2154816790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2013 | ||||||||
| LastUpdateDate: | 01/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP013125 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.