Provider Demographics
NPI:1982738555
Name:WALCZAK, SHARLENE MAE (RN)
Entity Type:Individual
Prefix:MRS
First Name:SHARLENE
Middle Name:MAE
Last Name:WALCZAK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3974 5TH ST NE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-3639
Mailing Address - Country:US
Mailing Address - Phone:763-788-2168
Mailing Address - Fax:
Practice Address - Street 1:2003 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-4531
Practice Address - Country:US
Practice Address - Phone:612-706-2526
Practice Address - Fax:612-781-1288
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR141389-0171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator