Provider Demographics
NPI:1235945551
Name:EDWARD, MARYKUTTY
Entity type:Individual
Prefix:MRS
First Name:MARYKUTTY
Middle Name:
Last Name:EDWARD
Suffix:
Gender:
Credentials:
Other - Prefix:MISS
Other - First Name:MARYKUTTY
Other - Middle Name:
Other - Last Name:AUGUSTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:552 WILLIAM PENN WAY
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-4174
Mailing Address - Country:US
Mailing Address - Phone:267-222-0468
Mailing Address - Fax:
Practice Address - Street 1:2901 JOLLY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-2324
Practice Address - Country:US
Practice Address - Phone:610-272-8221
Practice Address - Fax:610-272-5655
Is Sole Proprietor?:No
Enumeration Date:2024-12-10
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP031472363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner