Provider Demographics
NPI:1477389435
Name:VIVAS, THERESE (CRNP)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:VIVAS
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 1:814 CRESTVIEW RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-2303
Mailing Address - Country:US
Mailing Address - Phone:267-761-8890
Mailing Address - Fax:
Practice Address - Street 1:919 CONESTOGA RD BLDG 1
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-1352
Practice Address - Country:US
Practice Address - Phone:610-525-6580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP030615363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology