Provider Demographics
NPI:1497153472
Name:PROVINE, COURTNEY ANN (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:ANN
Last Name:PROVINE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MISS
Other - First Name:COURTNEY
Other - Middle Name:ANN
Other - Last Name:BURWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:5709 SHETLAND CT
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020
Mailing Address - Country:US
Mailing Address - Phone:267-760-1174
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:2 SOUTH
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-615-0718
Practice Address - Fax:215-349-8309
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014616363LF0000X
PASP021617363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4324295OtherCIGNA PA
PA3120472OtherHIGHMARK BLUE SHIELD
PA1029886820001Medicaid
PA5764869OtherAETNA
PAP01435312OtherRAILROAD MEDICARE
PA30218673OtherKEYSTONE FIRST
PAP01435312OtherRAILROAD MEDICARE