Provider Demographics
NPI:1710230461
Name:MOSTOVYK, ELIZABETH ANNE (CRNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:MOSTOVYK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 OBERLIN AVE
Mailing Address - Street 2:
Mailing Address - City:DELRAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08075-1309
Mailing Address - Country:US
Mailing Address - Phone:215-534-6947
Mailing Address - Fax:
Practice Address - Street 1:2601 HOLME AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2007
Practice Address - Country:US
Practice Address - Phone:215-335-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP012330363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP012330OtherLICENSE