MEDICARE: MARY KATHRYN WOLTJEN CNM CRNP RN

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	163W00000X	Registered Nurse	RN279256L	PA
2	363L00000X	Nurse Practitioner	TP004106G	PA
3	364SW0102X	Women's Health Clinical Nurse Specialist	MW008564L	PA

General Provider Information

NPI Number	:	1932185576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KATHRYN WOLTJEN CNM CRNP RN

Provider Business Mailing Address
First Line	:	623 UNRUH AVE
Second Line	:	2ND FL
City	:	PHILA
State	:	PA
Zip	:	19111-4709
Country	:	US
Telephone Number	:	215-214-1094
Fax Number	:	215-214-1098

Provider Business Practice Location Address
First Line	:	7604 CENTRAL AVE
Second Line	:	SUITE 101
City	:	PHILA
State	:	PA
Zip	:	19111-2433
Country	:	US
Telephone Number	:	215-745-8989
Fax Number	:	215-745-9072

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

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	09/11/2025

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