Provider Demographics
NPI:1326077637
Name:KOWALCZYK, STACY (CRNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:KOWALCZYK
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 1:12053 CAMPBELL RD
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-5621
Mailing Address - Country:US
Mailing Address - Phone:814-827-8829
Mailing Address - Fax:
Practice Address - Street 1:339 W SPRING ST
Practice Address - Street 2:SUITE 102
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354-1655
Practice Address - Country:US
Practice Address - Phone:814-827-9675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP005917B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS81834Medicare UPIN
PAKO027860Medicare ID - Type Unspecified