Healthcare Provider Details

I. General information

NPI: 1962003277
Provider Name (Legal Business Name): MARY C WICZEK APRN,CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 W DIVISION ST
SAINT CLOUD MN
56301-3926
US

IV. Provider business mailing address

2420 W DIVISION ST
SAINT CLOUD MN
56301-3926
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 866-389-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7722
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: