1588477566 NPI number — FELICIA BORTSOO BORKETEY PMHNP

Table of content: FELICIA BORTSOO BORKETEY PMHNP (NPI 1588477566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588477566 NPI number — FELICIA BORTSOO BORKETEY PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BORKETEY
Provider First Name:
FELICIA
Provider Middle Name:
BORTSOO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588477566
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
703 SANTA ANITA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH WALES
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19454-4295
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
703 SANTA ANITA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH WALES
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19454-4295
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-592-1220
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/31/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  SP031407 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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