Provider Demographics
NPI:1083070601
Name:WISHNOFF, JOANNA
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:WISHNOFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1632 PINE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-6711
Mailing Address - Country:US
Mailing Address - Phone:215-735-7992
Mailing Address - Fax:
Practice Address - Street 1:6701 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2459
Practice Address - Country:US
Practice Address - Phone:215-333-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP015593364SP0200X, 363LF0000X, 364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN616816OtherREGISTERED NURSE
PASP015593OtherCERTIFIED REGISTERED NURSE PRACTITIONER