Provider Demographics
NPI:1558094052
Name:MUMMERY, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MUMMERY
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 1:4701 PINE ST APT F11
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-7009
Mailing Address - Country:US
Mailing Address - Phone:646-812-3870
Mailing Address - Fax:
Practice Address - Street 1:CHILDREN'S HOSPITAL OF PHILADELPHIA
Practice Address - Street 2:550 SOUTH GODDARD BLVD
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406
Practice Address - Country:US
Practice Address - Phone:646-812-3870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-03
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT172417163W00000X
PASP026192363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse