Provider Demographics
NPI:1700875804
Name:CIESZYKOWSKI, MARILYN (NP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:CIESZYKOWSKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1251
Mailing Address - Street 2:
Mailing Address - City:DOLORES
Mailing Address - State:CO
Mailing Address - Zip Code:81323-1251
Mailing Address - Country:US
Mailing Address - Phone:970-882-7221
Mailing Address - Fax:970-882-8483
Practice Address - Street 1:507 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DOLORES
Practice Address - State:CO
Practice Address - Zip Code:81323-0908
Practice Address - Country:US
Practice Address - Phone:970-882-7221
Practice Address - Fax:970-882-4243
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17661363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P36529Medicare UPIN
803056Medicare ID - Type Unspecified