Healthcare Provider Details

I. General information

NPI: 1376618421
Provider Name (Legal Business Name): MARCIA DEVALK RN, CNS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7066 STILLWATER BLVD N
OAKDALE MN
55128-3937
US

IV. Provider business mailing address

7066 STILLWATER BLVD N
OAKDALE MN
55128-3937
US

V. Phone/Fax

Practice location:
  • Phone: 651-777-5222
  • Fax: 651-777-5222
Mailing address:
  • Phone: 651-777-5222
  • Fax: 651-777-5222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1462896
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number035189102
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number035189102
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: