MEDICARE: MRS. STACYLYNNE BOLKS FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	SP012846	PA
2	363L00000X	Nurse Practitioner	SP012846	PA

General Provider Information

NPI Number	:	1356684377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACYLYNNE BOLKS FNP-BC

Provider Business Mailing Address
First Line	:	3803 W CHESTER PIKE STE 160
Second Line	:
City	:	NEWTOWN SQUARE
State	:	PA
Zip	:	19073-2336
Country	:	US
Telephone Number	:	610-642-3005
Fax Number	:	610-642-3057

Provider Business Practice Location Address
First Line	:	100 E LANCASTER AVE
Second Line	:	SUITE 280 MEDICAL SCIENCE BUILDING
City	:	WYNNEWOOD
State	:	PA
Zip	:	19096-3450
Country	:	US
Telephone Number	:	610-642-3005
Fax Number	:	610-642-3057

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2013
Last Update Date	:	03/13/2026

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Directions to “ MRS. STACYLYNNE BOLKS FNP-BC” Practice Location

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