Provider Demographics
NPI:1376618421
Name:DEVALK, MARCIA (RN, CNS, MS)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:DEVALK
Suffix:
Gender:F
Credentials:RN, CNS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7066 STILLWATER BLVD N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-3937
Mailing Address - Country:US
Mailing Address - Phone:651-777-5222
Mailing Address - Fax:651-777-5222
Practice Address - Street 1:7066 STILLWATER BLVD N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-3937
Practice Address - Country:US
Practice Address - Phone:651-777-5222
Practice Address - Fax:651-777-5222
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1462896163W00000X
MN035189102363LP0808X, 364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN432686500OtherMEDICAL ASSISTANCE
MN432686500OtherMEDICAL ASSISTANCE
MN766851040714Medicare UPIN
MN011J2DEMedicare UPIN
MNHP32623Medicare UPIN
MN6277093Medicare UPIN
MN151429Medicare UPIN