Provider Demographics
NPI:1164204608
Name:OSADZE, ILONA (FNP-C, CRNP)
Entity type:Individual
Prefix:
First Name:ILONA
Middle Name:
Last Name:OSADZE
Suffix:
Gender:F
Credentials:FNP-C, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:882 HENRY AVE
Mailing Address - Street 2:
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-2600
Mailing Address - Country:US
Mailing Address - Phone:347-893-2207
Mailing Address - Fax:
Practice Address - Street 1:2900 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-1437
Practice Address - Country:US
Practice Address - Phone:215-660-9330
Practice Address - Fax:215-660-9336
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-18
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PASP028448363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program