Provider Demographics
NPI:1497204788
Name:DEVIVO, LORETTA ANN (APN-C)
Entity Type:Individual
Prefix:MS
First Name:LORETTA
Middle Name:ANN
Last Name:DEVIVO
Suffix:
Gender:F
Credentials:APN-C
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:ANN
Other - Last Name:DEVIVO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APN-C
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1627 CHEW ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18102-3648
Practice Address - Country:US
Practice Address - Phone:610-969-3390
Practice Address - Fax:610-969-3393
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00672700363LG0600X
PASP016766363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology