Provider Demographics
NPI:1376791004
Name:KEPHART, LEA JANEEN
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:JANEEN
Last Name:KEPHART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEA
Other - Middle Name:JANEEN
Other - Last Name:LANNUTTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:914 E CATHEDRAL RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1204
Mailing Address - Country:US
Mailing Address - Phone:215-508-2694
Mailing Address - Fax:
Practice Address - Street 1:321 NORRISTOWN RD STE 100
Practice Address - Street 2:
Practice Address - City:AMBLER
Practice Address - State:PA
Practice Address - Zip Code:19002-2793
Practice Address - Country:US
Practice Address - Phone:267-640-4675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-06
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUP006012H363LG0600X
PARN507305L163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP02134Medicare UPIN
PA036184Medicare PIN