Provider Demographics
NPI:1700274131
Name:KUSHNIR, MARYBETH (CRNP)
Entity type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
Last Name:KUSHNIR
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 1:1225 DERMOND RD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-4901
Mailing Address - Country:US
Mailing Address - Phone:484-454-5674
Mailing Address - Fax:
Practice Address - Street 1:30 LAWRENCE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3301
Practice Address - Country:US
Practice Address - Phone:484-446-3588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014591363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily