Provider Demographics
NPI:1215275144
Name:HIMMONS, MERCEDES ANGELIQUE (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:MERCEDES
Middle Name:ANGELIQUE
Last Name:HIMMONS
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 ROBERTS AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1207
Mailing Address - Country:US
Mailing Address - Phone:267-994-6161
Mailing Address - Fax:
Practice Address - Street 1:1325 SUMNEYTOWN PIKE
Practice Address - Street 2:
Practice Address - City:GWYNEDD VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19437
Practice Address - Country:US
Practice Address - Phone:215-624-6840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0054002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer