Healthcare Provider Details

I. General information

NPI: 1700875804
Provider Name (Legal Business Name): MARILYN CIESZYKOWSKI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 CENTRAL AVE
DOLORES CO
81323-0908
US

IV. Provider business mailing address

PO BOX 1251
DOLORES CO
81323-1251
US

V. Phone/Fax

Practice location:
  • Phone: 970-882-7221
  • Fax: 970-882-4243
Mailing address:
  • Phone: 970-882-7221
  • Fax: 970-882-8483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17661
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: