Healthcare Provider Details

I. General information

NPI: 1720488778
Provider Name (Legal Business Name): MS. MARGERY WALENTUK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 UNION ST
LYNN MA
01901-1314
US

IV. Provider business mailing address

24 WARREN ST
NEWBURYPORT MA
01950-2232
US

V. Phone/Fax

Practice location:
  • Phone: 978-581-3900
  • Fax:
Mailing address:
  • Phone: 978-609-1681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN217947
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: