Provider Demographics
NPI:1265985600
Name:FAVANO, LEIA MAREE (CRNP)
Entity type:Individual
Prefix:
First Name:LEIA
Middle Name:MAREE
Last Name:FAVANO
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 1:139 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLYN
Mailing Address - State:PA
Mailing Address - Zip Code:19094-1717
Mailing Address - Country:US
Mailing Address - Phone:484-574-3400
Mailing Address - Fax:
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014746363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily