Provider Demographics
NPI:1992030845
Name:MACDERMOTT, MARYLOU (CRNP)
Entity Type:Individual
Prefix:
First Name:MARYLOU
Middle Name:
Last Name:MACDERMOTT
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 1:37 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:HADDON TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-2351
Mailing Address - Country:US
Mailing Address - Phone:856-240-1854
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:THE CHILDREN'S HOSPITAL FOR CHILDREN
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-590-6539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-09
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP002261N363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics