Provider Demographics
NPI:1043802648
Name:RODRIGUEZ, AWILDA
Entity Type:Individual
Prefix:
First Name:AWILDA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AWILDA
Other - Middle Name:
Other - Last Name:VALENTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:830 OLD LANCASTER RD STE 206
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3118
Mailing Address - Country:US
Mailing Address - Phone:484-380-3094
Mailing Address - Fax:
Practice Address - Street 1:830 OLD LANCASTER RD STE 206
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3118
Practice Address - Country:US
Practice Address - Phone:484-380-3094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023218363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care