Provider Demographics
NPI:1285191197
Name:MAFOUOTI, JOELLE M (CRNP)
Entity Type:Individual
Prefix:
First Name:JOELLE
Middle Name:M
Last Name:MAFOUOTI
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2501 W LEHIGH AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132-3207
Mailing Address - Country:US
Mailing Address - Phone:215-227-0300
Mailing Address - Fax:215-227-0302
Practice Address - Street 1:120 BURRUS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BRODHEADSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18322-7812
Practice Address - Country:US
Practice Address - Phone:570-420-6300
Practice Address - Fax:570-402-2920
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP020030363LF0000X
PASP020022163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse