Provider Demographics
NPI:1912504978
Name:KRZYSTOWCZYK, MARY MARGARET (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARGARET
Last Name:KRZYSTOWCZYK
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 1:524 W THIRTEENTH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4014
Mailing Address - Country:US
Mailing Address - Phone:248-404-8867
Mailing Address - Fax:
Practice Address - Street 1:930 N LOGAN ST APT 1/2
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-3193
Practice Address - Country:US
Practice Address - Phone:248-404-8867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAG01200132363LG0600X, 363LP2300X
MI4704301134363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology