Provider Demographics
NPI:1245630433
Name:NICK, MARY JAYNE (CRNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JAYNE
Last Name:NICK
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 1:8000 CRANBERRY SPRINGS DR FL 1
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TWP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-6687
Mailing Address - Country:US
Mailing Address - Phone:724-720-3098
Mailing Address - Fax:
Practice Address - Street 1:8000 CRANBERRY SPRINGS DR FL 1
Practice Address - Street 2:
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066-6687
Practice Address - Country:US
Practice Address - Phone:724-720-3098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2025-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014079363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily