Provider Demographics
NPI:1932185576
Name:WOLTJEN, MARY KATHRYN (CNM CRNP RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:WOLTJEN
Suffix:
Gender:F
Credentials:CNM CRNP RN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:GERNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:623 UNRUH AVE
Mailing Address - Street 2:2ND FL
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-4709
Mailing Address - Country:US
Mailing Address - Phone:215-214-1094
Mailing Address - Fax:215-214-1098
Practice Address - Street 1:7604 CENTRAL AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19111-2433
Practice Address - Country:US
Practice Address - Phone:215-745-8989
Practice Address - Fax:215-745-9072
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN279256L163W00000X
PATP004106G363L00000X
PAMW008564L364SW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Not Answered364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P18472Medicare UPIN
PA043644JTQMedicare ID - Type Unspecified