Provider Demographics
NPI:1073050928
Name:BACHALIS, SOPHEA (CRNP)
Entity Type:Individual
Prefix:
First Name:SOPHEA
Middle Name:
Last Name:BACHALIS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 CIVIC CENTER BLVD
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5127
Mailing Address - Country:US
Mailing Address - Phone:215-349-8222
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:4TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5127
Practice Address - Country:US
Practice Address - Phone:215-349-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017123363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner