Provider Demographics
NPI:1689640120
Name:WALCZAK, MARILYN L (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:L
Last Name:WALCZAK
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 1:3434 CEDAR GLEN DR
Mailing Address - Street 2:
Mailing Address - City:ALLISON PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15101-1073
Mailing Address - Country:US
Mailing Address - Phone:724-443-6740
Mailing Address - Fax:
Practice Address - Street 1:4849 WILLIAM FLYNN HWY
Practice Address - Street 2:
Practice Address - City:ALLISON PARK
Practice Address - State:PA
Practice Address - Zip Code:15101-2319
Practice Address - Country:US
Practice Address - Phone:724-443-2418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP004385B363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS63052Medicare UPIN
PA017042PD8Medicare ID - Type Unspecified
PA017042XRNMedicare PIN
PA017042XRUMedicare PIN