Provider Demographics
NPI:1790961480
Name:DEITRICK, GINNA ELIZABETH (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:GINNA
Middle Name:ELIZABETH
Last Name:DEITRICK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:GINNA
Other - Middle Name:ELIZABETH
Other - Last Name:SYLVANUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-3005
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:INTERVENTIONAL RADIOLOGY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-3005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN556396163WX0200X
PASP009820363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WX0200XNursing Service ProvidersRegistered NurseOncology